Emergencies, including power shutoffs, can interrupt your normal routine and support systems.
Planning ahead could increase the odds that your access and functional needs are met if you
evacuate quickly or shelter in place. Taking responsibility by creating a disaster plan and to-go bag
is the first step in maintaining your health and independence. All your information should be current
and because it is personal keep it in a safe but handy place in your home.
Identify your capabilities now and what assistance you may need after a disaster by filling out this
information sheet. Think in terms of everyday necessities but also your unique needs, which may
include medications, assistive devices, service animals and support services. Skip those that do
not pertain to you.
Personal Information
Name: _________________________________________________ Date of Birth: _____ /_____ / _______
First Last Middle
Address:___________________________________________________________________________________
Street City State Zip
Phone: ______________ Mobile: _______________ Social Network Contact: ___________________
Emergency Contacts
1) Someone who does not live with you
Name: ________________________________________________ Phone: __________________________
First Last Middle
2) Someone from out-of-state
Name: _________________________________________________ Phone: __________________________
First Last Middle
Health Providers
1) Agency/Personal Care
Name: __________________________________________ Phone: __________________________
2) Evacuation/Transportation Support
Name: _________________________________________________ Phone: __________________________
Personal Emergency Plan
2
3) Primary Physician
Name: _________________________________________________ Phone: __________________________
4) Pharmacy
Name: __________________________________________________ Phone: ________________________
5) Insurance
Name: _________________________________________________ Phone: __________________________
6) Allergies and Sensitives/Reactions
7) Dietary Restrictions
Medication Information
1) Please check one:
I take my own medication
Someone gives medications to me
2) List of current medications
Medication
Dosage
Frequency
How taken?
Refrigerated?
1.
2.
3.
4.
5.
6.
7.
8.
Personal Emergency Plan
3
Medical Devices
1) Medical Devices/Assistive Technology Vendor
Name: _________________________________________________ Phone: __________________________
2) Backup batteries/electricity needed?
Yes
No
3) Do you have low to no hearing?
Yes
No
If you answered yes, check all that apply:
Wears a hearing aid
Uses sign language
Uses pictures
Can read
4) Do you have low to no vision?
Yes
No
If you answered yes, check all that apply:
I use braille for reading
I wear eyeglasses
I wear contact lenses
5) Do you have a service animal who must evacuate with you?
Yes
No
If you answered yes, my service animal’s name is _______________________________________
Veterinarian’s Name: _______________________________ Phone: __________________________
6) I need help with:
7) To help calm me during an emergency:
8) Safety Precautions:
Personal Emergency Plan
4
Go-Bag Checklist
Personal Items:
Completed information sheet
Extra clothing
Cash
Credit card
Cell phone/charger
Bottled water
Snacks
Comfort items
Medical:
Medications
Pain reliever
Antacid
Catheters
Tubing
Syringes
Inhaler
Extra eyeglasses and case
Diabetes supplies
Hearing aid batteries
Mask
Toiletries:
Travel size shampoo/conditioner
Soap
Deodorant
Tissues
Toothbrush
Toothpaste
Denture solution
Contact solution
Contact case
Extra contacts
Comb or brush
Moist towelettes
Hand sanitizer
First aid kit
Food and treats for service animal
Play toys
Waste disposal bags
Bedding
Extra leash or tie
Copies of Important Documents:
Birth certificate
Photo ID
Health insurance card
Home/car insurance
Guardianship papers
Proof of address
Bank account numbers
These are only suggested items. Please determine what meets your needs.
Personal Emergency Plan
5
Sheltering Checklist
Essentials:
Water supply (for 3 days)
Water for sanitation
Nonperishable food (for 3 days)
Manual can opener
Battery operated radio
Battery operated flashlight
Extra batteries
Whistle
Medical:
Medication (for 7 days)
Pain reliever
Antacid
Vitamins
Laxative
Medical supplies (for 7 days)
Toiletries:
Shampoo/conditioner
Soap
Deodorant
Tissues
Toothbrush
Toothpaste
Toilet paper
Household Items:
Paper towels
Trash bags
First aid kit
Bleach
Matches
Candles
Baby supplies
Pet supplies
If you are storing these supplies, make sure they are in a sealed waterproof container,
preferably placed high off the ground. Creating and maintaining these supplies may be too
expensive. Determine what you will need to maintain your health. Work with your providers,
family, friends or faith-based groups to help you create a shelter in place kit.
Next Steps
Have an action plan with family, providers and vendors letting them know how they can
support you should you need to evacuate or shelter in place. Have at least three different
means of transportation if you do not have your own vehicle. Make sure all your identified
support people know that they are in your plan. Consider giving a copy of your house key
to one of your support people if you are comfortable with that. Contact local utilities
companies if you are dependent on power for assistive devices. Learn how to shut off your
utilities. Review your plan with your support system at least annually and keep all important
information current.