Prepare.org: Disaster Preparedness for People With Disabilities

Appendix C: Important Lists

TABLE OF CONTENTS:

• Emergency Information List
• Medical Information List
• Disability-Related Supplies and Special Equipment List

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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