Person-Centred Emergency Management Plan

Accommodation Provider Contacts:

Emergency Contacts/Next of Kin/Adult Guardian/Enduring Power of Attorney:

I have the following health documents:

Advanced Care Plan documentAdvance Health Directive/Statement of ChoicesAcute Resuscitation PlanAdult Guardianship/Enduring Power of AttorneyPositive Behaviour Support PlanNoneOther
Medical Information

My Medical Contacts:

	Name	Phone Number	Email Address	Address
Doctor
Local Hospital with 24-hour Emergency
Pharmacist

My Medical Conditions:

	Yes	No	Plan to manage condition during and after an emergency
Heart Disease
Diabetes
Asthma
Migranes
Fainting Spells
Anxiety
Epilepsy
High Blood Pressure
Thyroid Problems
Dizziness
Chronic Pain

Daily Personal Activities:

	Full Assist	Partial Assist/Prompt	N/A	Comments
Showering
Dressing
Grooming (E.g., shaving, brushing hair)
Skin Integrity
Oral Care
Continence
Mobility
Mealtime Management (E.g., Dysphagia)
Medication/BGL
Laundry

Primary Disability:
E.g., Intellectual, Acquired Brain Injury, Autism
Secondary Disability:
I am on Clozapine:

YesNo
Allergies or Adverse Reactions?

YesNoUnsure
Details of Allergies or Adverse Reactions:
E.g., Allergic to Penicillin.
Communication and Behaviours
I can usually communicate verbally?

YesNoMinimally
This helps me talk to you:

SymbolsPicturesGesturingFacial expressionsSimple wordsWhen you wait for me to respondMy supports/carerOther
This helps me to understand you:

Short, plain sentencesSimple wordsSolid examplesDiagrams or picturesMaking sure I understandAsking me to repeat it backAsking my supports/carer to explain it to meUsing objectsGiving me a demonstrationOther
The best way to communicate with me is:

Speaking directly to meTaking time to tell meWaiting for me to respondWriting down notesKnowing that I cannot talk but can hear and understandOther
Normal behaviours for me:
E.g., Sometimes I pace back and forth in a room but this is normal for me.
Things that make me anxious or nervous and what to do:
E.g., I don't like being around dogs, please take me to another quiet place to calm down.
What are the main risks in your community?

HeatwaveStormCycloneBushfireFloodEarthquakeTsunamiLandslideHouse firePower outageHealth emergency (e.g., like COVID-19)
How would these emergencies affect you?

Alternative contacts in case I'm displaced from my normal residence:

How will I communicate with family and services outside of my home if I have to isolate?
Should be Empty:

CONTACT NUMBERS