Checklist, Personal Assessment, and Personal Support Network and Contacts

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

Preparedness101@hotmail.com

preparedness101@hotmail.com



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