Each person with the disability or need should accomplish what is called a personal support network contact list (family members, attendants, neighbors...)
This is a sample and should be adjusted to fit the needs of the person. Add additional contacts as needed. Set these recommendations up on a word document or spread sheet.
Checklist and Personal Assessment:
During an emergency, this checklist will enable emergency responders to better assist you.
I am able to:
Hear?
See?
Walk without help?
Walk with help?
Prepare my meals?
Feed myself?
Dress myself?
Sit without help?
Wash/bath without help?
Wash/bath with help?
Sanitary needs without help?
Sanitary needs with help?
I need specific help with (explain).
Personal Support Network Contact List (Family members, Attendents, neighbors...)
Name:
Relation:
Address:
Phone (Home):
Phone (Business):
Allergies:
Other Special Needs:
Special Diets:
Health Card #
Private Medical:
Policy #
Neighborhood Contact:
Out-of-town emergency contact:
School Contact:
Household pet care:
Veterinarian phone:
Local emergency management contact (for your area):
Blessings,
Bravo Echo Out
