Finish all required in the checklist, 

and also create    
“Draw a floor plan of your home and attach it to submission; mark two escape routes from each room. “

Please read requirement carefully!

Family Disaster Plan Checklist

For this assignment, you will complete Your Family’s Disaster Plan Checklist adapted from Appendix A of your ReadyRN text. 

This week 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 one of the following, located in the Worksheets, Forms, and Templates area at left: 

· Family Disaster Plan Checklist (PDF)
or

· Family Disaster Plan Checklist (Word doc)

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

Complete the Assignment Checklist. Check off items that you have in inventory.

• 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

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

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

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.

My Family’s Disaster Plan

Learn about the natural disasters that could occur in your community and how you can respond

to them. Provide at least two references and sources of information. Use APA Style for your

reference.

Possible hazards in my area:

1.____________________ APA source reference: _____________________

_____

2. ____________________ APA source reference: ____________________

______

3. ________________________________________________

4. ________________________________________________

5. ________________________________________________

6. ________________________________________________

Emergency Phone Numbers

(Program these into all phones and post in a common area in the home.)

• Police department:

• Fire department:

• Local emergency services:

• Healthcare provider(s):

• Local American Red Cross:

• Poison Help: 1-800-222-1212

• Other local emergency personnel numbers: ___________________

• ___________________

• ___________________

Employers and School Officials Contacts

I know the emergency response plans for employers and schools. _____

School:

Address:

Phone:

Contact name:

Child Day Care/School Phone #

Employer:

Address:

Phone:

Contact name:
Employer:
Address:
Phone:
Contact name:

Family Communication Plan

Prepare a family communication plan so that each member of the family can contact one

another quickly.

• Everyone has a cell phone or calling card _____

• Young children know how to call (numbers are saved) ______

Name Contact Name Phone Email

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

Near your home:

Location:

Address:

Phone:

Away from your home (in the event you cannot return home):

Location:
Address:
Phone:

Draw a floor plan of your home and attach it to your submission; mark two escape routes

from each room. ______

Pick a friend or relative who lives out of the area for household members to call/email to say

they are okay.

Name:

Phone:

Email:

Everyone in the house knows how and when to shut off utilities. ______

Utility Name Number Shut-Off Location/Main Controls

Electric

Water

Gas

Evacuation Plan and Transportation

Extra gallon of gas ______

Local government resource ______

Contact person/agency:

Address:

Phone:

Certifications

Stay current and up to date (e.g., CPR, ACLS, PALS, TNCC).

• Certification #1:

• Date of Completion/renewal:

• Certification #2:

• Date of Completion/renewal:

• Certification #3:

• Date of Completion/renewal:

Property, Health, and Financial Well-being

Review property insurance policies for disaster policies. ______

Current ______

Appropriate to needs ______

Review life-insurance policies. ______

Current ______

Appropriate to needs ______

Review health insurance policies. ______

Current ______
Appropriate to needs ______

Review financial documents. ______

Emergency savings $______

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
Photocopied Items

That are Safely
Stored

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:

Consider ways to help neighbors who may need special assistance (ESL/medical/living alone).

Name Special Help Needed Address Phone

Pet Arrangements

As per local and state health and safety regulations, pets are not permitted in some shelters

such as American Red Cross shelters. Service animals are permitted.

Name of shelter vet:

Address:
Phone:

Names of pet friendly hotels/motels or friends/family out of the area:

Name:
Address:
Phone:

Name:
Address:
Phone:

Name:
Address:
Phone:

Special Needs Assistance

Special needs assistance organization in community.

Name:
Address:
Phone:

Register with local office of emergency services or fire department.

Name:
Address:
Phone:

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. _____

Disaster Supply Kit “Go Bag”

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

Home: Make sure all family members know where the go bags are and have access them.

_____

Specific go bags:

Pet go bag _____

Child go bag with special items for feeling safe and staying occupied _____

Car: 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. Check off

the supplies you have on hand and indicate the date the supply needs to be refreshed.

• Two quarts of water daily for drinking for each person in household. _____

• Extra two quarts of water daily for children, nursing mothers, and those who are ill and

need more. _____

• One gallon/week supply of water stored for sanitary and cooking needs for household.

_____

Change water every 6 months.

• Update water supplies _____________ (date)

Safety Tip: Water Storage and Collection in an Emergency

• Do not store 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.

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.

Stock high energy protein foods in go bags:

Peanut butter ______

Trail mix ______

Granola bars ______

Peanuts ______

Hard candy ______

Boxed juices ______

Powdered milk ______

Dry fruits______

Keep infant foods and special diet foods in supply. ______

First Aid Supplies

Assemble a first aid kit for your home and each vehicle. ______

Check off all of 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 eye glasses or contacts______

Nonprescription drugs:

Aspirin and non—aspirin pain relievers ______

Antidiarrheal medication ______

Antacid______

Laxative______

Vitamins______

Syrup of ipecac ______

Tools and Emergency Supplies

Assemble these items in a disaster supply kit in case you need to leave quickly.

Check off all of the basic items you have and list additional specialty items you have on hand.

Tools

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 ______

Sanitation and Hygiene

Washcloth and towel ______

Towelletes, 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 ______

Kitchen Items

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 ______

If food must be cooked, a small camping stove and can of cooking fuel ______

Clothes and Bedding

One complete change of clothes and footwear for each member of 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. ______

Specialty Items as Needed For:

The baby ______

The elderly ______

Pets ______

Other Items

Add a list of additional items to include here. Review other disaster preparedness websites for

items not included here. Check off items that you have and list items you need to acquire.

Item

Included