Emergency Preparedness

Emergency Preparedness Information

(Contact us for a hard copy of this form). Independence Empowerment Center knows that you know yourself better than anyone else does and therefore you know best how to take care of yourself. However, we would like to help you collect all of the information you might need in case of an emergency. This information will then be available if you need it in a hurry. We have designed a form for your use which we hope you will find helpful. Fill it is as completely as possible, place it in a small Ziploc bag and keep it where you can get to it quickly and easily. If there is something left off of this form that you feel you will need, please add it at the end.

Date Originally Prepared:___________________________

Your Name:_______________________________________

Revision Date:____________________________________

Emergency Preparedness Information

Your Contact Information:

Your address:

_________________________________________________

Your Phone Number (please enter cell phone number if possible)

_________________________________________________

Your Social Security Number:

_________________________________________________

Name of local family or friend:

_________________________________________________

Their phone number(s):

_________________________________________________

Out of town close relative or friend:

_________________________________________________

Their phone number(s):

_________________________________________________

Doctor’s Information:

Name of Your Physician:

_________________________________________________

Type of Physician:

_________________________________________________

Your Physician’s Address:

_________________________________________________

Your Physician’s Phone #:

_________________________________________________

Name of Your Key Specialist:

_________________________________________________

Area of Speciality:

_________________________________________________

Specialist’s Address:

_________________________________________________

Specialist’s Phone #:

_________________________________________________

Name of Medicine Dosage (e.g. 100mg)

______________________ ______________________

How to Take Medicine How often?

______________________ ______________________

Name of Medicine Dosage (e.g. 100mg)

______________________ ______________________

How to Take Medicine How often?

______________________ ______________________

Name of Medicine Dosage (e.g. 100mg)

______________________ ______________________

How to Take Medicine How often?

______________________ ______________________

Name of Medicine Dosage (e.g. 100mg)

______________________ ______________________

How to Take Medicine How often?

______________________ ______________________

Do any of these medicines need to be stored in a cooler? If so, remember to take your cooler!

If your disability deals with communication barriers, how is the best way to communicate with you?

_________________________________________________

Necessary equipment that needs to go with you (for example, a walker or a specific breathing apparatus):

_________________________________________________

Allergies (medicine, food, etc.)

_________________________________________________

Insurance Information

Home Insurance

Name of Insurance:

_________________________________________________

Type:

_________________________________________________

Card Number/ID Number:

_________________________________________________

Group # (if applicable):

_________________________________________________

Phone Number:

_________________________________________________

Health Insurance

Name of Insurance:

_________________________________________________

Type:

_________________________________________________

Card Number/ID Number:

_________________________________________________

Group # (if applicable):

_________________________________________________

Phone Number:

_________________________________________________

***Also, remember to store copies of your important documents in the Ziploc bag. Such copies might include: birth certificate, passport, driver’s license, insurance information, or proof of address.

Living Will is on file at:

_________________________________________________

Health Care Proxy is on file at:

_________________________________________________

Do you have an EMS-NO CPR Directive or a DNR form?

( ) Yes ( ) No

Where is it located:

_________________________________________________

Meeting Places:

Plan alternate ways to exit your home and let someone know of your plan.

Established meeting place with family/care givers (for example, a certain nearby library):

_________________________________________________