Name: Date: Revise Date:
One of the most important steps you can take in preparing for emergencies is to develop a household disaster plan. This involves creating a plan that identifies who you can contact in an emergency, what each member of your family must do, and how you can better prepare yourself for the situation. See Appendix A in your text. (Veenema, 2009)
Assignment Instructions:
Complete the Family Disaster Plan Checklist
- Complete all sections. Use yes, no, check marks or x’s for items you do have. Use need, for items you do not have at this time. Use N/A, for items not applicable for your living situation. Do not leave anything blank.
- Remember to protect personal information by using pseudonyms, or by providing only partial information
- Ex: Sister: Britley *****, phone: 724-***-****, email: b********@yahoo.com
- Use complete information for utility and public companies.
- Review the rubric for more information on how the assignment will be graded.
- Please note: You are not required to purchase any items on this list, however, take note of the items you are missing and consider how it could impact your safety and survival in a disaster.
- Complete the “My Family’s Disaster Plan”. Include your reference and in text citations.
My Family’s Disaster Plan
Research potential disasters that could occur in your community. Select 2 (two) potential disasters and using about 25 words, examine how these potential disasters can impact you as a nurse. Provide at least 1 reference for each potential disaster. Use APA Style for your reference(s) and in text citation(s).
Possible hazards in my area # 1
Reference
Possible hazards in my area # 2
Reference
____________________________________________________________________________
Emergency Phone Numbers – (Program these into all phones and post in a common area in the home.)
| Address | Phone # | |
| Police Department | ||
| Fire Department | ||
| Local Emergency Services | ||
| Local American Red Cross | ||
| Poison Help | 1-800-222-1212 | |
| Healthcare Providers | ||
| Doctor | ||
| Dentist | ||
| Other (add additional important personal contacts) |
Employers and School Officials Contacts
I know the emergency response plans for employers and schools. _____
For yourself, spouse, and significant other:
| Employer/School | Address | Phone # | Facility Contact Name |
For children:
| Child’s Name | Child Day Care/Child School | Address | Phone # | Facility Contact Name |
Family Communication Plan
Prepare a family communication plan so that each member of the family can contact one another quickly. (Put 10 most important numbers on a card in your wallet.)
- Everyone has a cell phone or calling card _____
- Young children know how to call (numbers are saved) ______
| Name | Contact Name | Phone | |
Identify two meeting places for your family in the event that you are separated.
Location near your home:
| Location | Address | Phone | |
Location away from your home (in the event you cannot return home):
| Location | Address | Phone | |
Pick at least 1 or 2 friends or relatives who live out of the area for household members to call/email to say they are okay. (If you want, add others as backup.)
| Name | Phone | Address | |
Draw a floor plan of your home. Mark two escape route pathways from each room to each exit. You may use this space to draw your floor plan or imbed a photo. You may attach your drawing page to the end of this document ~OR~ Attach as a 2nd document to your assignment submission (Do not submit the document as a 2nd submission attempt. It will negate your 1st submission attempt. Submit as an additional document in 1 attempt. If you still have questions on how to submit this assignment, please ask before submitting.)
______
Everyone in the house knows how, when and where to shut off utilities. ______
| Utility Name | Phone Number | Shut-Off Location/Main Controls at your residence |
| Electric | ||
| Water | ||
| Gas |
Evacuation Plan and Transportation
Extra gallon of gas ______
If you do not have a car, make plans with a neighbor or your local government agency to be evacuated.
| Neighbor/Local Government Agency | Phone Number | Address |
_____________________________________________________________________________
Property, Health, and Financial Well-being
Review property insurance policies for disaster policies. ______
Current ______ Appropriate to needs ______
Review life-insurance policies. ______
Current ______ Appropriate to needs ______
Review health insurance policies. ______
Current ______ Appropriate to needs ______
Review financial documents. ______
Emergency savings $______ Easily accessible, small cash savings $ ______
Important Documents and Items Secured
Make sure you have copies of important documents and items that can be stored in a fireproof watertight container.
| Important Items | Check off photocopied items that are safely stored |
| Personal identification | |
| Cash and coins | |
| Credit card(s) | |
| Extra set of house keys and car keys | |
| Birth certificate | |
| Marriage certificate | |
| Driver’s license | |
| Social Security card | |
| Passport/visa | |
| Wills | |
| Deeds | |
| Inventory of household goods (with photos & serial numbers) | |
| Insurance papers | |
| Immunization records AllergiesMedications | |
| Bank and credit card numbers | |
| Stock/bonds | |
| Emergency contact list (phone/address/email) | |
| Local map and emergency shelter locations | |
| Pet information | |
| Additional: | |
______________________________________________________________________________
Pet Arrangements
As per local and state health and safety regulations, pets are not permitted in some shelters such as American Red Cross shelters. Service animals are permitted.
Name of Veterinarian and Name of Local Animal Shelter:
| Name of Veterinarian | Address | Phone | |
| Name of Local Animal Shelter | Address | Phone | |
Names of pet friendly hotels/motels or friends/family out of the area:
| Name | Address | Phone | |
______________________________________________________________________________
Special Needs Assistance
Special needs assistance organization in community.
| Name | Address | Phone | |
Register with your local office of emergency services or fire department.
| Name | Address | Phone | |
Consider ways to help neighbors who may need special assistance (ESL/medical/living alone).
| Name | Special Help Needed | Address | Phone |
Create a network of neighbors, friends, relatives, coworkers to aid you in an emergency
- Mobility escape chair in place _____
- High-rise/apartment arrangements for emergency evacuation _____
- Extra wheelchair batteries, oxygen, catheters, medications, food for service animals _____
- Caregiver identification information _____
- Medical bracelet, etc. _____
_____________________________________________________________________________
Certifications
Stay current and up to date (e.g., CPR, ACLS, PALS, TNCC).
| Certification | Date of Completion | Date of Renewal |
_____________________________________________________________________________
Disaster Supply Kit “Go Bag”
You and your family may need to survive on your own for 3 days or more. Consider having additional supplies for up to two weeks confinement or shelter. You should prepare emergency supplies for the following situations:
Go Bags
Make sure all family members know where the go bags are and have access to them.
Home go bag _____
Pet go bag _____
Child go bag with special items for feeling safe and staying occupied _____
Car go bag – 3-day supplies included with emergency roadside equipment _____
Work go bag _____
Water Supplies
Stocking water supplies should be a top priority. Drinking water in emergency situations should not be rationed. It is critical to store adequate amounts of water for your household.
Check off all of the basic items you have and list additional specialty items you have on hand:
| Water Change water every 6 months. | On Hand | Need to Acquire | Next water change _____________ (date) |
| Two quarts of water daily for drinking for each person in your household | |||
| One gallon/week supply of water stored for sanitary and cooking needs for your household. | |||
| Additional Specialty Items: | On Hand | Need to Acquire | Next water change _____________ (date) |
| Extra two quarts of water daily for children, nursing mothers, and those who are ill and need more. |
Safety Tip: Water Storage and Collection in an Emergency
- Do not store in glass containers or other containers that can break.
- Do not rely on untested devices for decontaminating water.
- If you have a well or public water, follow treatment methods provided by your public health service or water provider.
- Store water in a cool, dark place.
Food: Preparing and Emergency Supply
Food, unlike water may be rationed except for children and pregnant women. No special food needed. Keep canned foods and dry mixes stocked. Replenish food supplies every 6 months. Use and replace. Store newer items in the back, older items in front.
Check off all of the basic items you have and list additional specialty items you have on hand:
| High energy protein foods | On Hand | Need to Acquire |
| Peanut butter | ||
| Trail mix | ||
| Granola bars | ||
| Peanuts | ||
| Hard candy | ||
| Boxed juices | ||
| Powdered milk | ||
| Dry fruits | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
Add items you need for your family situation:
| Infant foods | On Hand | Need to Acquire |
| Specialty diet foods | On Hand | Need to Acquire |
First Aid Supplies
Assemble a first aid kit for your home. ______
Assemble a first aid kit for each vehicle. ______
Check off all of the basic items you have and list additional specialty items you have on hand:
| Basic First Aid Supplies | On Hand | Need to Acquire |
| First aid manual | ||
| Sterile adhesive bandages, assorted sizes | ||
| Safety pins assorted sizes | ||
| Cleansing agents | ||
| Antibiotic ointment | ||
| Latex gloves (2 pair) | ||
| Petroleum jelly or other lubricant | ||
| 2-inch and 4-inch sterile gauze pads (4 to 6 of each) | ||
| Triangular bandages (3) | ||
| Sunscreen | ||
| Scissors | ||
| 2-inch and 3-inch sterile roller bandages (3 rolls each) | ||
| Tweezers | ||
| Needle | ||
| Moistened towelettes | ||
| Antiseptic | ||
| Thermometer | ||
| Tongue depressor blades (2) | ||
| Prescription medication list (ask your pharmacist about storing prescription medications) | ||
| Extra pair or prescription eyeglasses or contacts | ||
| Nonprescription drugs: | On Hand | Need to Acquire |
| Aspirin and non—aspirin pain relievers | ||
| Antidiarrheal medication | ||
| Antacid | ||
| Laxative | ||
| Vitamins | ||
| Syrup of ipecac | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
Tools and Emergency Supplies
Assemble these items in a disaster supply kit in case you need to leave quickly.
Check off all of the basic items you have and list additional specialty items you have on hand:
| Tools | On Hand | Need to Acquire |
| Portable, battery-powered radio, TV, alarm clock | ||
| Flashlight and extra batteries | ||
| Signal flare | ||
| Matches in a waterproof container | ||
| Shut-off wrench, pliers, shovel, hammer, screwdriver, and other tools | ||
| Duct tape and scissors | ||
| Plastic sheeting | ||
| Whistle | ||
| A-B-C fire extinguisher | ||
| Tube tent | ||
| Compass | ||
| Work gloves | ||
| Paper, pen, pencils | ||
| Needles and thread | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
Check off all of the basic items you have and list additional specialty items you have on hand:
| Sanitation and Hygiene | On Hand | Need to Acquire |
| Washcloth and towel | ||
| Towelettes, soap, hand sanitizer, liquid detergent | ||
| Toiletries | ||
| Heavy-duty plastic garbage bags | ||
| Medium–sized plastic bucket with tight lid and small shovel for digging a latrine. | ||
| Disinfectant and household chlorine bleach | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
Check off all of the basic items you have and list additional specialty items you have on hand:
| Kitchen Items | On Hand | Need to Acquire |
| Manual can opener | ||
| Mess kits or paper cups, plates, plastic utensils | ||
| All-purpose knife | ||
| A dropper (eye dropper) with measurements | ||
| Liquid bleach to treat water Only use regular, unscented chlorine bleach products that are suitable for disinfection and sanitization as indicated on the label. The label may say that the active ingredient contains 6 or 8.25% of sodium hypochlorite. Do not use scented, color safe, or bleaches with added cleaners. If water is cloudy, let it settle and filter it through a clean cloth, paper towel, or coffee filter. | ||
| Sugar, salt, pepper | ||
| Aluminum foil, plastic wrap | ||
| Resealing plastic bags | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
| If food must be cooked, a small camping stove and can of cooking fuel | ||
Check off all of the basic items you have and list additional specialty items you have on hand:
| Clothes and Bedding | On Hand | Need to Acquire |
| One complete change of clothes and footwear for each member of the household. Shoes should be sturdy work shoes or boots. | ||
| Rain gear, hats and gloves, extra socks and underwear, thermal underwear, sunglasses. | ||
| Blankets or sleeping bags and pillows for each member. | ||
| Additional Specialty Items: | On Hand | Need to Acquire |
Check off all of the basic items you have and list additional specialty items you have on hand:
| Specialty Items as needed for Baby | On Hand | Need to Acquire |
Check off all of the basic items you have and list additional specialty items you have on hand:
| Specialty Items as needed for Elderly | On Hand | Need to Acquire |
Check off all of the basic items you have and list additional specialty items you have on hand:
| Specialty Items as needed for Pets | On Hand | Need to Acquire |
Other Items
Review other disaster preparedness websites for items not included here.
Check off items that you have and list items you need to acquire.
| Item | Included |
