Name: Date: Revise Date:
One of the most important steps you can take in preparing for emergencies is to develop a household disaster plan. This involves creating a plan that identifies who you can contact in an emergency, what each member of your family must do, and how you can better prepare yourself for the situation. See Appendix A in your text. (Veenema, 2009)
Assignment Instructions:
Complete the Family Disaster Plan Checklist
1. Complete all sections. Use yes, no, check marks or x’s for items you do have. Use need, for items you do not have at this time. Use N/A, for items not applicable for your living situation. Do not leave anything blank.
2. Remember to protect personal information by using pseudonyms, or by providing only partial information
o Ex: Sister: Britley *****, phone: 724-***-****, email: b********@yahoo.com
3. Use complete information for utility and public companies.
4. Review the rubric for more information on how the assignment will be graded.
5. Please note: You are not required to purchase any items on this list, however, take note of the items you are missing and consider how it could impact your safety and survival in a disaster.
6. Complete the “My Family’s Disaster Plan”. Include your reference and in text citations.
My Family’s Disaster Plan
Research potential disasters that could occur in your community. Select 2 (two) potential disasters and using about 25 words, examine how these potential disasters can impact you as a nurse. Provide at least 1 reference for each potential disaster. Use APA Style for your reference(s) and in text citation(s).
Possible hazards in my area # 1
Reference
Possible hazards in my area # 2
Reference
____________________________________________________________________________
Emergency Phone Numbers – (Program these into all phones and post in a common area in the home.)
Address Phone #
Police Department
Fire Department
Local Emergency Services
Local American Red Cross
Poison Help 1-800-222-1212
Healthcare Providers
● Doctor
● Dentist
● Other (add additional important personal contacts)
Employers and School Officials Contacts
I know the emergency response plans for employers and schools. _____
For yourself, spouse, and significant other:
Employer/School Address Phone # Facility Contact Name
For children:
Child’s Name Child Day Care/Child School Address Phone # Facility Contact Name
Family Communication Plan
Prepare a family communication plan so that each member of the family can contact one another quickly. (Put 10 most important numbers on a card in your wallet.)
● Everyone has a cell phone or calling card _____
● Young children know how to call (numbers are saved) ______
Name Contact Name Phone Email
Identify two meeting places for your family in the event that you are separated.
Location near your home:
Location Address Phone Email
Location away from your home (in the event you cannot return home):
Location Address Phone Email
Pick at least 1 or 2 friends or relatives who live out of the area for household members to call/email to say they are okay. (If you want, add others as backup.)
Name Phone Email Address
Draw a floor plan of your home. Mark two escape route pathways from each room to each exit. You may use this space to draw your floor plan or imbed a photo. You may attach your drawing page to the end of this document ~OR~ Attach as a 2nd document to your assignment submission (Do not submit the document as a 2nd submission attempt. It will negate your 1st submission attempt. Submit as an additional document in 1 attempt. If you still have questions on how to submit this assignment, please ask before submitting.)
______
Everyone in the house knows how, when and where to shut off utilities. ______
Utility Name Phone Number Shut-Off Location/Main Controls at your residence
Electric
Water
Gas
Evacuation Plan and Transportation
Extra gallon of gas ______
If you do not have a car, make plans with a neighbor or your local government agency to be evacuated.
Neighbor/Local Government Agency Phone Number Address
_____________________________________________________________________________
Property, Health, and Financial Well-being
Review property insurance policies for disaster policies. ______
Current ______ Appropriate to needs ______
Review life-insurance policies. ______
Current ______ Appropriate to needs ______
Review health insurance policies. ______
Current ______ Appropriate to needs ______
Review financial documents. ______
Emergency savings $______ Easily accessible, small cash savings $ ______
Important Documents and Items Secured
Make sure you have copies of important documents and items that can be stored in a fireproof watertight container.
Important Items Check off photocopied items that are safely stored
Personal identification
Cash and coins
Credit card(s)
Extra set of house keys and car keys
Birth certificate
Marriage certificate
Driver’s license
Social Security card
Passport/visa
Wills
Deeds
Inventory of household goods (with photos & serial numbers)
Insurance papers
Immunization records
— Allergies
— Medications
Bank and credit card numbers
Stock/bonds
Emergency contact list (phone/address/email)
Local map and emergency shelter locations
Pet information
Additional:
______________________________________________________________________________
Pet Arrangements
As per local and state health and safety regulations, pets are not permitted in some shelters such as American Red Cross shelters. Service animals are permitted.
Name of Veterinarian and Name of Local Animal Shelter:
Name of Veterinarian Address Phone Email
Name of Local Animal Shelter Address Phone Email
Names of pet friendly hotels/motels or friends/family out of the area:
Name Address Phone Email
______________________________________________________________________________
Special Needs Helpance
Special needs Helpance organization in community.
Name Address Phone Email
Register with your local office of emergency services or fire department.
Name Address Phone Email
Consider ways to help neighbors who may need special Helpance (ESL/medical/living alone).
Name Special Help Needed Address Phone
Create a network of neighbors, friends, relatives, coworkers to aid you in an emergency
● Mobility escape chair in place _____
● High-rise/apartment arrangements for emergency evacuation _____
● Extra wheelchair batteries, oxygen, catheters, medications, food for service animals _____
● Caregiver identification information _____
● Medical bracelet, etc. _____
_____________________________________________________________________________
Certifications
Stay current and up to date (e.g., CPR, ACLS, PALS, TNCC).
Certification Date of Completion Date of Renewal
_____________________________________________________________________________
Disaster Supply Kit “Go Bag”
You and your family may need to survive on your own for 3 days or more. Consider having additional supplies for up to two weeks confinement or shelter. You should prepare emergency supplies for the following situations:
Go Bags
Make sure all family members know where the go bags are and have access to them.
Home go bag _____
Pet go bag _____
Child go bag with special items for feeling safe and staying occupied _____
Car go bag – 3-day supplies included with emergency roadside equipment _____
Work go bag _____
Water Supplies
Stocking water supplies should be a top priority. Drinking water in emergency situations should not be rationed. It is critical to store adequate amounts of water for your household.
Check off all of the basic items you have and list additional specialty items you have on hand:
Water
Change water every 6 months. On Hand Need to Acquire Next water change _____________ (date)
Two quarts of water daily for drinking for each person in your household
One gallon/week supply of water stored for sanitary and cooking needs for your household.
Additional Specialty Items: On Hand Need to Acquire Next water change _____________ (date)
Extra two quarts of water daily for children, nursing mothers, and those who are ill and need more.
Safety Tip: Water Storage and Collection in an Emergency
● Do not store in glass containers or other containers that can break.
● Do not rely on untested devices for decontaminating water.
● If you have a well or public water, follow treatment methods provided by your public health service or water provider.
● Store water in a cool, dark place.
Food: Preparing and Emergency Supply
Food, unlike water may be rationed except for children and pregnant women. No special food needed. Keep canned foods and dry mixes stocked. Replenish food supplies every 6 months. Use and replace. Store newer items in the back, older items in front.
Check off all of the basic items you have and list additional specialty items you have on hand:
High energy protein foods On Hand Need to Acquire
Peanut butter
Trail mix
Granola bars
Peanuts
Hard candy
Boxed juices
Powdered milk
Dry fruits
Additional Specialty Items: On Hand Need to Acquire
Add items you need for your family situation:
Infant foods On Hand Need to Acquire
Specialty diet foods On Hand Need to Acquire
First Aid Supplies
Assemble a first aid kit for your home. ______
Assemble a first aid kit for each vehicle. ______
Check off all of the basic items you have and list additional specialty items you have on hand:
Basic First Aid Supplies On Hand Need to Acquire
First aid manual
Sterile adhesive bandages, assorted sizes
Safety pins assorted sizes
Cleansing agents
Antibiotic ointment
Latex gloves (2 pair)
Petroleum jelly or other lubricant
2-inch and 4-inch sterile gauze pads (4 to 6 of each)
Triangular bandages (3)
Sunscreen
Scissors
2-inch and 3-inch sterile roller bandages (3 rolls each)
Tweezers
Needle
Moistened towelettes
Antiseptic
Thermometer
Tongue depressor blades (2)
Prescription medication list (ask your pharmacist about storing prescription medications)
Extra pair or prescription eyeglasses or contacts
Nonprescription drugs: On Hand Need to Acquire
Aspirin and non—aspirin pain relievers
Antidiarrheal medication
Antacid
Laxative
Vitamins
Syrup of ipecac
Additional Specialty Items: On Hand Need to Acquire
Tools and Emergency Supplies
Assemble these items in a disaster supply kit in case you need to leave quickly.
Check off all of the basic items you have and list additional specialty items you have on hand:
Tools On Hand Need to Acquire
Portable, battery-powered radio, TV, alarm clock
Flashlight and extra batteries
Signal flare
Matches in a waterproof container
Shut-off wrench, pliers, shovel, hammer, screwdriver, and other tools
Duct tape and scissors
Plastic sheeting
Whistle
A-B-C fire extinguisher
Tube tent
Compass
Work gloves
Paper, pen, pencils
Needles and thread
Additional Specialty Items: On Hand Need to Acquire
Check off all of the basic items you have and list additional specialty items you have on hand:
Sanitation and Hygiene On Hand Need to Acquire
Washcloth and towel
Towelettes, soap, hand sanitizer, liquid detergent
Toiletries
Heavy-duty plastic garbage bags
Medium–sized plastic bucket with tight lid and small shovel for digging a latrine.
Disinfectant and household chlorine bleach
Additional Specialty Items: On Hand Need to Acquire
Check off all of the basic items you have and list additional specialty items you have on hand:
Kitchen Items On Hand Need to Acquire
Manual can opener
Mess kits or paper cups, plates, plastic utensils
All-purpose knife
A dropper (eye dropper) with measurements
Liquid bleach to treat water
● Only use regular, unscented chlorine bleach products that are suitable for disinfection and sanitization as indicated on the label. The label may say that the active ingredient contains 6 or 8.25% of sodium hypochlorite. Do not use scented, color safe, or bleaches with added cleaners. If water is cloudy, let it settle and filter it through a clean cloth, paper towel, or coffee filter.
Sugar, salt, pepper
Aluminum foil, plastic wrap
Resealing plastic bags
Additional Specialty Items: On Hand Need to Acquire
If food must be cooked, a small camping stove and can of cooking fuel
Check off all of the basic items you have and list additional specialty items you have on hand:
Clothes and Bedding On Hand Need to Acquire
One complete change of clothes and footwear for each member of the household. Shoes should be sturdy work shoes or boots.
Rain gear, hats and gloves, extra socks and underwear, thermal underwear, sunglasses.
Blankets or sleeping bags and pillows for each member.
Additional Specialty Items: On Hand Need to Acquire
Check off all of the basic items you have and list additional specialty items you have on hand:
Specialty Items as needed for Baby On Hand Need to Acquire
Check off all of the basic items you have and list additional specialty items you have on hand:
Specialty Items as needed for Elderly On Hand Need to Acquire
Check off all of the basic items you have and list additional specialty items you have on hand:
Specialty Items as needed for Pets On Hand Need to Acquire
Other Items
Review other disaster preparedness websites for items not included here.
Check off items that you have and list items you need to acquire.
Item
Included
