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 Person:____________________________
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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