DISASTER PREPAREDNESS FOR PEOPLE WITH DISABILITIES
APPENDIX C: IMPORTANT LISTS
TABLE OF CONTENTS:
Emergency Information List
Please complete this form and distribute copies to your emergency contact people, as well as to
each member in your network.
Name:________________________________
Birth Date:____________________________
Address:______________________________
_____________________________________
_____________________________________
Telephone Number:_____________________
Social Security Number:_________________
Local Emergency Contact:________________
Local Emergency Contact's Home/Work/Cell Numbers:
_____________________________________
_____________________________________
_____________________________________
Network Members:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Network Members' Home/Work/Cell Numbers:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Out-of-town Contact Person:______________
Out-of-town Contact's Home/Work/Cell Numbers:
_____________________________________
_____________________________________
_____________________________________
How best to communicate with me:
_____________________________________
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Medical Information List
Please complete this form and distribute copies to your emergency contact people as well as to
each member in your network.
Primary Physician:______________________
Telephone Number:_____________________
Address:______________________________
_____________________________________
_____________________________________
Hospital Affiliation:______________________
Address:______________________________
_____________________________________
_____________________________________
Type of Health Insurance:________________
Policy Number:_________________________
Blood type:____________________________
Allergies and Sensitivities:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Medications and Dosages Being Taken:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Specific Medical Conditions:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Physical Limitations:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Adaptive Equipment and Vendors' Phones:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Communication Difficulties:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Cognitive Difficulties:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
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Disability-Related Supplies and Special Equipment List
Check items you use, and describe item type and location. Distribute copies to your emergency
contact people as well as to each member in your network.
- ________ Glasses:
- ________ Eating utensils:
- ________ Grooming utensils:
- ________ Dressing devices:
- ________ Writing devices:
- ________ Hearing device:
- ________ Oxygen:
- ________ Oxygen Flow Rate:
- ________ Suction equipment:
- ________ Dialysis equipment:
- ________ Sanitary supplies:
- ________ Urinary supplies:
- ________ Ostomy supplies:
- ________ Wheelchair:
- ________ Wheelchair repair kit:
- ________ Motorized:
- ________ Manual:
- ________ Walker:
- ________ Crutches:
- ________ Cane(s):
- ________ Dentures:
- ________ Monitors:
- ________ Other:
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