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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:



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...)




Phone (Home):

Phone (Business):


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):


Bravo Echo Out

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