09 Oct Family Disaster Plan Checklist

Family Disaster Plan Checklist NURS 431 Disaster Management

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

· ​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

______________________________________________________________________________