Emergency Preparedness Checklist
PHASE IName: Triage Level: / Yes / No / N/A / Comments
Is there someone available who can perform your care? If yes,
Name: Ph#: Relation:
Do you have transportation?
Are you going to leave your home? If no skip to emergency contact.
Where are you going?
Address:
City:
Phone:
Do you need assistance to leave your home?
Do you have your insurance information ready for evacuation?
Are you going to a shelter? If no, go to next question.
Name of Shelter:
Address:
City: Zip: Phone:
Are you on Oxygen?
Do you have extra tanks?
Name of DME provider:
Phone: Fax:
Do you have a generator?
Do you have enough wound care supplies for 7 days?
If not what is needed?
Do you have established emergency plan?
Do you have the phone #s to call for help?
Are you registered with the 211program?
If no, would you like to be registered services?
PATIENT DECLARATION
I understand that I only have up to 2 days prior to the predicted possible disaster strikes to enroll in the 211 program for assistance with transportation to evacuate my home. I have made other arrangements or I plan to stay at home until a mandatory evacuation is ordered. I understand the consequences of my decision at this time. Pt signature: Date:
DECLARACION DEL PACIENTE
Yo entiendo que tengo solo 2 días antes de el desastre pronosticado pare registrarme en el programa de 211 para garantizar asistencia en transportación en caso de que la área tener que ser evacuada. Yo he hecho otros arreglos y por lo pronto intento quedarme en casa hasta que se declare una evacuación mandada. Y además, yo entiendo las consecuencias que resulten se decido quedarme en casa durante el desastre de pronosticado. Firma del Paciente: Fecha:
PHASE II
Date: ______Status: £Returned Home £Remains at Shelter £Remains w/ Family
Person Contacted: ______£Unable to return d/t environmental hazards £ Services may resume
Comments:
TRANSPORTATION ASSISTANCE REGISTRY
Fax to 866-557-1074
Date of Survey Response:
Do you have transportation to evacuate? □ Yes □ No
First Name:
Last Name:
Street Address:
City:
Zip Code:
Phone Number: (___)
Sex: □ Female □ Male
In case of emergency contact:
First Name:
Last Name:
Relationship:
Phone Number: (___)
If others are evacuating with you, how many?
Do you have a pet? □ Yes □ No
If yes, how many ______Do you have carriers for every pet? □ Yes □ No
Do you have medical special needs? □ Yes □ No
(One who needs assistance during evacuation and sheltering because of physical or mental handicaps OR one who requires a level of care and resources beyond the basic first aid level of care that is available in shelters for the general population.)
Do you or anyone evacuating with you use oxygen? □ Yes □ No
What category describes your special needs?
Level 1 □ A person dependent on others or in need of others for routine care (eating, walking, toileting, etc.). Child
under 18 without adult supervision, etc.
Level 2 □ A person who is blind, hearing impaired, deaf/blind, or has an amputation.
Level 3 □ A person needing assistance with medical care administration, monitoring by a nurse, dependent on equipment, assistance with medications, mental health disorders.
Level 4 □ A person outside an institutional facility care setting who require extensive medical oversight (i.e., IV
chemotherapy, ventilator, peritoneal dialysis, hemodialysis, life support equipment, hospital bed and total
care, or is morbidly obese)
Level 5 □ A person in institutional setting such as hospitals, long-term care/assisted living facilities, or state schools.
Do you use a service animal? □ Yes □ No
If you selected Level 3, 4 or 5: Do you use a wheelchair? □ Yes □ No
Are you confined to a bed? □ Yes □ No
Do you require power for medical equipment? □ Yes □ No
Call 211 for evacuation assistance County Emergency Management Coordinators:
Salvation Army 1-800-725-2769 Hidalgo Co. A .A .“Tony” Pena Jr. 956-318-2615 McAllen 956-661-0930
Red Cross: Hidalgo Co. 956-423-0523 Cameron Co. Johnny Cavazos 956-547-7000 Edinburg 956-318-2615
Costal Bend 361-877-9991 Willacy Co. Frank Torres 956-689-5456 Harlingen 956-366-3600
San Antonio 210-224-5151 Costal Bend Randy Sijansky 361- 826-1100 Road Conditions 1-800-452-9292