Personal Disaster Plan

Personal Disaster Plan
Consumer Name:

First NameLast Name
Consumer Name (Related family in Same Residence):

First NameLast Name
Consumer Name(Related family in Same Residence:

First NameLast Name
Consumer Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consumer Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact:

First NameLast Name
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Providing Agency Name:
Supported Living Coach:

First NameLast Name
SLC Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Copies of Disaster Plan to be provided to:
PLAN A: My Personal Plan to Shelter in Place:

My first choice will always be to shelter in my own home unless County Emergency Management mandates evacuation, or the emergency situation makes me feel that I may not be safe if I remain in my home.
I have the following Supplies:
The supports who helped me to ensure that all the above has been completed, all equipment is in working order, and that all personal information is current on a quarterly basis is:
I require the following special dietary supplies, durable medical equipment and/or consumable medical supplies:
Type of required Supplies (oxygen, feeding tube):
If I need assistance as I shelter in my home, this person(s) will remain with me in my home:

First NameLast Name
Phone number of individual staying with you in your home.
Please enter a valid phone number.Format: (000) 000-0000.
Plan B: My Personal Plan When I Must Evacuate:

If I must evacuate my home during an emergency or disaster, I am prepared to follow this plan:
I have the following:

Go Kit (I have an easy-to-carry "Go Kit" prepared that contains or can be readily packed to contain the following supplies that I have reserved in my home and will take with me to the shelter: at least a 7-day supply of meds; Items required for special diet; a 3-day supply of water and non-perishable food and snacks; personal hygiene essentials; first aid kit; battery-operated radio and extra batteries; flashlight and extra batteries; cash; cell phone and charger; bedding/sleeping bag; at least one complete change of clean dry clothing; glasses; hearing aids; durable and consumable medical supplies; waterproof container that has copies of all of my important documents; multipurpose utility tool; whistle; matches/lighter; rain gear; games, books, entertainment supplies.
I will Evacuate to one of these locations if I can evacuate within the area:
First Choice:
Name, Address & Phone Number
Second Choice: If circumstances prevent me from evacuating to my first choice, I will evacuate to:
Name, Address & Phone Number
I have transportation arranged to get to both my first and second choices for both of my in-area and out-of-area evacuation destinations.
If Yes, who has committed to assisting you in evacuating?
Name & Phone Number
If you need assistance when you evacuate, who will remain with you for the duration of evacuation?
Name & Phone Number
Plan C: My Personal Plan if I must Go to a Shelter or Medical facility:

I understand that shelters operated by County Emergency Management and the Health Department are available but should only be used as a last resort and as a back-up to My Personal Sheltering Plans A and B. Note: Shelters may be crowded, noisy, lack privacy and may be especially challenging for persons with behavioral health needs. However, if circumstances make it necessary for me to go to a shelter or medical facility; this is my plan:
I have determined what type of shelter or medical facility that I will need to go to:

Special Needs Shelter (I will need to go to a special needs shelter because I need electricity for life supporting medical equipment, or basic nursing care, or oxygen therapy, or observation/monitoring by a healthcare professional, or assistance with medication andno one to assist me, or a chronic condition that requires assistance from a healthcare professional, or special medical requirements that do not require hospitalization or another special need that cannot be accommodated in a general population shelter. My condition may warrant a caregiver to go with me to a Special Needs Shelter to care for me while I shelter there)
If Applicable, general population Shelter
Name & Location
If Applicable, Special Needs Shelter
Name & Location
If Applicable, Medical Facility
Name & Location
This person helped me determine where I need to go:

First NameLast Name
Transportation: I have identified how I will get to my designated shelter
Person or agency providing transportation:
Name & phone Number
My Personal Commitment Disaster Preparedness:
I understand the following:
Consumer Signature:
Supports/Guardian Signature
Signature Date:

MonthDayYear
Date
Should be Empty:

Personal Disaster Plan

PLAN A: My Personal Plan to Shelter in Place:

Plan B: My Personal Plan When I Must Evacuate:

I will Evacuate to one of these locations if I can evacuate within the area:

Plan C: My Personal Plan if I must Go to a Shelter or Medical facility:

My Personal Commitment Disaster Preparedness: