Family's disaster plan checklist

For this assignment, you will complete Your Family’s Disaster Plan Checklist.

You will gather and complete the recommended information and supplies listed on the Family Disaster Plan Checklist Checklist.

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.

a. Download the Family Disaster Plan Checklist and fill out everything.

b. Complete all sections. For the inventory lists, use a check mark to show which items you have on hand.

For items that are not applicable to you and your living situation, please write N/A (not applicable) in the space, otherwise, it will be counted as incomplete.
Remember to protect personal information by using pseudonyms, or by providing only partial information
- Ex: Sister: Britley *****, phone: 724-***-****, email: b********@yahoo.com

Family Disaster Plan Checklist NURS 431 Disaster Management

Assignment Instructions:

Complete your Family Disaster Plan Checklist

1. Complete all sections I – VIII. Use yes, check marks or x’s for items
you do have. Use need or no for items you
do not have currently. Use N/A, for items not applicable for your living situation.
Do not leave anything blank.

2. Remember to
protect personal information by using pseudonyms, or by providing only partial information.

· Ex: Sister: Britley *****, phone: 724-***-****, email:
b********@yahoo.com

3. Use complete information for utility companies, public companies, and agencies.

4.
Review the rubric for more information on how the assignment will be graded.

5.
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.

6. Complete Section I. – “My Family’s Disaster Plan-Potential Hazards”. Include your reference and in-text citations.

____________________________________________________________________________

Name: Date: Revise Date:

(This is generally done annually

unless you have life changes.)

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. (Veenema, 2009)

I.

My Family’s Disaster Plan – Potential Hazards

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 include in-text citation(s).
Write your word count at the end of your paragraph for each possible hazard.

# 1-Possible hazards in my area:

Reference

# 2-Possible hazards in my area:

Reference

II.

Emergency Contact Information and Communication Plan

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. _____
Self, Spouse, Significant Other (names)	Employer/School	Address	Phone #	Facility Contact Name

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 and they also have the 10 most important numbers on a card in their backpack.) ______
10 most important numbers	Name	Address	Phone	Email
1
2
3
4
5
6
7
8
9
10

Identify two meeting places for your family, in the event you are separated.

One Location NEAR your home (neighbor/local friend):
Location	Address	Phone	Email

One Location AWAY from your home, in the event you cannot return home (school, recreation center, fire department, police station):
Location	Address	Phone	Email

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	Address	Phone	Email

III.

Emergency Floorplan, Utilities Shut-Off, Evacuation Plan and Transportation
1. Draw a floor plan of your residence and label all exterior doors and windows.

2.
Mark two escape route pathways, using arrows, out of each room.

(See example below: Bastrop County Office of Emergency Management).

· Use this space to draw your floor plan or imbed a photo OR

· You may attach your drawing to the end of this document OR

· Attach it 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.

Emergency Floorplan
Everyone in the house knows how, when, and where to shut off utilities, prior to a disaster. This is done to mitigate damage to your residence. ______
Utility Company Name	Utility Company Phone Number	Location of the Main Shut-Off or Main Controls at your residence
Electric Company Name
Water Company Name
Gas Company Name

Evacuation Plan and Transportation

· Extra gallon of gas ______

· If you do not have a car, do you have plans with a neighbor, family members or your local government agency to be evacuated. ______

List a neighbor/family member or 2 and a local government agency.

(Example: Area Rapid Transit)

Address

Phone

IV.

Property, Health, and Financial Well-being
(yes/no answers)

· Review property insurance policies and disaster policies. Are current and appropriate to my/my family’s needs ______

· Review life-insurance policies. Are they current and appropriate to my/my family’s needs ______

· Review health insurance policies. Are they current and appropriate to my/my family’s needs ______

· Review financial documents. ______

· Appropriate emergency savings (an average of 3 months household income) ______

· 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 items that are safely stored/photocopied
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 · Allergies · Medications
Bank and credit card numbers
Stock/bonds
Emergency contact list (phone/address/email)
Local map and emergency shelter locations
Pet information
Additional:

V.

Pet Arrangements

As per local and state health and safety regulations, pets may not be 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	Email

Name of Local Animal Shelter (Good to have if you find a lost pet.)	Address	Phone	Email

Names of pet friendly hotels/motels in and out of the area:
Name	Address	Phone	Email

VI.

Special Needs Assistance

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. _____

Special needs assistance organization in your community.
Name	Address	Phone	Email

Register with the local office of emergency services/preparedness or fire department.
Name	Address	Phone	Email

Consider ways to help neighbors who may need special assistance (ESL/medical/living alone).
Name	Special Help Needed	Address	Phone

VII. Certifications

Stay current and up to date (e.g., CPR, ACLS, PALS, TNCC).
Certification	Date of Completion	Date of Renewal

VIII. Disaster Supply Kit “Go Bag” and Emergency Supplies

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 _____

Vehicle 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.

Safety Tip: Water Storage and Collection in an Emergency

· Do not store it 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.

Water	On Hand	Need to Acquire	Next water change (date) *Change water every 6 months.*
Two quarts of water daily for drinking for each person in household
One gallon/week supply of water stored for sanitary and cooking needs for household.
Additional Specialty Items:	On Hand	Need to Acquire	Next water change (date) *Change water every 6 months.*
Extra two quarts of water daily for children, nursing mothers, and those who are ill and need more.

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.

High energy protein foods	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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: (Put N/A if it not applicable to your needs.)
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. _____

Basic First Aid Supplies	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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.

Tools	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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

Sanitation and Hygiene	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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

Kitchen Items	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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

Clothes and Bedding	On Hand	Need to Acquire
Check off all the basic items you have and list additional specialty items you have on hand:
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 bag and pillows for each member.
Additional Specialty Items:	On Hand	Need to Acquire

Specialty Items as needed for Baby	On Hand	Need to Acquire
Check off all 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 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
Check off all the basic items you have and list additional specialty items you have on hand:

Other Items

Review other disaster preparedness websites for items not included here.

List items that you have added to personalize your emergency preparedness Go Bag.
Item	Included

List items you need or would like to acquire to personalize your Go Bag.
Item	Included

2- Revised Summer 2023

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Family’s disaster plan checklist

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