Fillable Know Plan Prepare Booklet (Commonwealth of Massachusetts)

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Know Plan Prepare Booklet (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

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A PERSONAL PLANNING TOOL FOR INDIVIDUALS
WHO HAVE ACCESS AND FUNCTIONAL NEEDS
You and your family can be ready for emergencies.
Visit mass.gov/KnowPlanPrepare
KNOW
PLAN
PREPARE
Emergencies can happen at any time.
Planning ahead and being prepared
can lead to better outcomes for you
and your family.
This tool can be used individually or with family
members or caregivers. It can help you think about
what you need to support your daily living activities
during and after a disaster. Once you have identified
your needs, we recommend that you:
• Create a family or individual emergency plan
• Create an emergency preparedness kit
• Develop a contact list
Visit our website to find out
how to prepare an emergency
kit and build your family or
individual emergency plan.
mass.gov/KnowPlanPrepare
COMMUNICATION
Write down information about your communication needs.
These might include things like a pad of paper and pen,
hearing aids, portable magnifying glass, a communication
board or book, or other assistive tools. Consider dierent
ways of getting emergency notifications, such as TV, radio,
the internet, mobile apps, etc.
mass.gov/KnowPlanPrepare
Show Me for Emergencies is a free mobile
app that can assist people with comunication
challenges during emergencies.
Point your smartphone’s camera at
this code for more information.
Click here to start typing...
MEDICAL NEEDS / MAINTAINING
HEALTH
Write down information about your medications (including
dosage, time of day you take it, and what it is for). Include
information about related supplies and any ongoing
treatments you need. For example, what medication or
recurring medical services do you use? Do you have allergies
or other health conditions?
If you require oxygen, do you have a spare tank or
a way of contacting the supplier in an emergency?
If you have to evacuate from your home, what will
you need for your daily living activities?
Click here to start typing...
INDEPENDENCE
Write down information about assistive equipment,
prosthetics, and durable medical equipment (DME) you use
to function independently. Do you have enough supplies
to last 72 hours? Where would you get extra supplies? For
example, do you have extra batteries for portable devices, a
manual wheelchair in case your powered chair is damaged,
or extra eye glasses? Do you need extra feeding tubes,
diapers, formula, bandages, etc? List any supplies:
If you have a service animal, be
sure to include their supplies in
your emergency preparedness kit!
mass.gov/KnowPlanPrepare
ITEM: SUPPLIER/PHONE #:
Click here to start typing...
SERVICE / SUPPORT
Write down information about your support network.
Include anyone that needs to be on your contact list to
assist you during a disaster. For example: family and close
friends, Personal Care Attendant (PCA), others. Remember
to include any supports you may need for psychological or
emotional needs. Do you need help managing panic or PTSD
reactions, or help with completing a multi-step process?
Plan with your support network before a disaster
so they know you will need their assistance. Do
they know where your emergency kit is? Can they
operate any assistive devices you have? If you have
a plan for psychological emergencies such as a
Wellness Recovery Action Plan (WRAP), do your
support people know what it is and how to use it?
RELATIONSHIP: PHONE #:NAME:
Click here to start typing...
TRANSPORTATION
Write down information about your transportation needs.
Do you have access to private transportation? Do you use
mass transit or an accessible vehicle?
Do you have maps that
show alternate routes in
case main roads are closed,
or your usual method of
public transportation
becomes inaccessible?
mass.gov/KnowPlanPrepare
TRANSPORTATION COMPANY: PHONE #:
Click here to start typing...
After filling out this tool, put it in
a waterproof document bag and keep it in your
emergency preparedness kit along with copies
of other important documents (such as your
medical information, copies of identification,
financial information, etc.).
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH
MS2335
For more guides and resources, visit our
website (mass.gov/KnowPlanPrepare) or
point your smartphone’s camera at this code:
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Know Plan Prepare Booklet (Commonwealth of Massachusetts)

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Completed 19 July 2020

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