Fillable Personal Emergency Plan Form (California)

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Personal Emergency Plan Form (California)

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The Personal Emergency Plan Form (California) form is 5 pages long and contains:

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  • 83 check-boxes
  • 83 other fields

Country of origin: US
File type: PDF

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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 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.
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Personal Emergency Plan Form (California)

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Completed 17 February 2021

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