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Emergencies, including power shutoffs, can interrupt your normal (City of Carson, California)

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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 nique 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:
Social Network Contact: ______________________
Phone: __________________________
Phone: __________________________
First Last Middle
_____ /_____ / _______
Address: ___________________________________________________________________________________________
Street City State Zip
Phone: _________________ Mobile: _________________
Emergency Contacts
1) Someone who does not live with you
Name: _________________________________________________________
First Last Middle
2) Someone from out-of-state
Name: _________________________________________________________
First Last Middle
Health Providers
1) Agency/Personal Care
Name: _____________________________________________ Phone: __________________________
2) Evacuation/Transportation Support
Name: _________________________________________________________ Phone: __________________________
Phone: __________________________
5) Insurance
.
Medication
Dosage
Frequency
How taken?
Refrigerated?
1.
2
.
3.
4
.
5
.
6.
7
.
8
Personal Emergency Plan
3) Primary Physician
Name: _________________________________________________________
4) Pharmacy
Name: _________________________________________________________ Phone: __________________________
Name: _________________________________________________________ Phone: __________________________
6) Allergies and Sensitives/Reactions
7) Dietary Restrictions
1) Please check one:
2) List of current medications
Medication Information
☐ I take my own medication
☐ Someone gives medications to me
2
Phone: __________________________
3) Do you have low to no hearing?
4) Do you have low to no vision?
If you answered yes, my animal’s name is ________________________________________________________
Phone: __________________________
Personal Emergency Plan
Medical Devices
1) Medical Devices/Assistive Technology Vendor
Name: _________________________________________________________
2) Backup batteries/electricity needed?
☐ Yes
☐ No
☐ Yes
☐ No
If you answered yes, check all that apply:
☐ Wears a hearing aid
☐ Uses sign language
☐ Uses p ictures
☐ Can read
☐ Yes
☐ No
If you answered yes, check all that apply:
☐ I use brail for reading
☐ I wear eyeglasses
☐ I wear contact lenses
5) Do you have a service animal who must evacuate with you?
☐ Yes
☐ No
Veterinarian’s Name: ________________________________________
6) I need help with:
7) To help calm me during an emergency:
8) Safety Precautions:
3
Personal Emergency Plan
Go-Bag Checklist
Personal Items:
☐ Deodorant
☐ Tissues
☐ Toothbrush
☐ Toothpaste
☐ Denture solution
☐ Contact solution
☐ Contact case
☐ Extra eyeglasses and 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
☐ Completed information sheet
☐ Extra clothing
☐ Cash
☐ Credit card
☐ Cell phone/charger
☐ Bottled water
☐ Snacks
☐ Comfort items
☐ Other
Medical:
☐ Medications
☐ Pain reliever
☐ Antacid
☐ Catheters
☐ Tubing
☐ Syringes
☐ Inhaler
☐ Diabetes supplies
☐ Hearing aid batteries
☐ Mask
☐ Other
Copies of Important Documents:
☐ Birth certificate
☐ Photo ID
☐ Health insurance card
☐ Home/car insurance
☐ Guardianship papers
☐ Proof of address
☐ Bank account numbers
Toiletries:
☐ Travel size shampoo/conditioner
☐ Soap
These are only suggested items. Please determine what meets your needs.
4
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 i n place kit.
Personal Emergency Plan
Sheltering Checklist
Essentials: Toiletries:
☐ Water supply (for 3 days)
☐ Nonperishable food (for 3 days)
☐ Water for sanitation
☐ Manual can opener
☐ Battery operated radio
☐ Battery operated flashlight
☐ Extra batteries
☐ Whistle
☐ Shampoo/conditioner
☐ Soap
☐ Deodorant
☐ Tissues
☐ Toothbrush
☐ Toothpaste
☐ Toilet paper
Household Items:
Medical:
☐ Paper to wels
☐ Trash bags
☐ First aid kit
☐ Bleach
☐ Matches
☐ Candles
☐ Baby supplies
☐ Pet supplies
☐ Medication (for 7 days)
☐ Pain reliever
☐ Antacid
☐ Vitamins
☐ Laxative
☐ Medical supplies (for 7 days)
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.
5
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Completed 17 April 2021

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