DISASTER PREPAREDNESS COMMUNICATION LIST & SUPPLIES	MONTH/YEAR
Complete this form with signatures and submit to office for filing. One copy remains in the individual's home; one copy to the WSC.
Client Name
Address	Phone #
WSC Agency Name	Phone #
WSC Name	Phone #
SLC Name	Phone #
Other Staff Name	Phone #
Evacuation Zone	Evacuation Shelter
Family/Friend to contact in case of emergency	Name/Relationship

Address

Phone #
Primary Doctor

Name
Address	Phone #
Secondary Doctor

Name
Address	Phone #
Health Issues (List)

Attach a current list of all medications/dosage.
Medications?	YES	NO	Adaptive Equipment? (List on Supplies List, if needed)
Ambulatory?	YES	NO
Is this person registered with County Emergency Management as a person with special needs?	Month/Year Updated
Transportation arrangements for the individual in case of evacuation.

Emergency Management	Contact Person, if known.
Pinellas	727-464-3800	Pasco	727-847-8137	Hillsborough	813-236-3800	Other
Where is the individual during the day (work/day program)? Give name of place, location/address, phone number.
Name
Address	Phone #
Where will the individual go in case of mandatory evacuation?	How will the individual get there?	Person(s) responsible for individual.
Name, address/location, and phone number of evacuation shelter or family/friend the individual will stay with in case of emergency.
Name of person individual will stay with if necessary.	Name/Relationship
Address	Phone #
Name of person who will notify individual of potential disaster or need to evacuate.
Check each of the areas (supplies in stock and prepared) when completed. Use the attached list of supplies.
Disaster Supplies in stock	First Aid Supplies in stock	Evacuation Supplies Prepared
Plan for post-disaster follow up (describe). Ensure you have a plan to contact the APD area office to verify the individual's safety. The SLC will assess the individual's home for safety. If there is no damage, then the individual may return home. If there is damage, the SLC and individual will contact the home owner/manager. The SLC will assist the individual with finding temporary accommodations while repairs are made or more permanent alternative accommodations if necessary. If needed, the SLC will contact the Red Cross for assistance.

Contact APD area office to verify safety of individual.	1-800-615-8720 (APD Suncoast Region Office)
Contact WSC to verify safety of individual.
In case of evacuation, ensure transportation is arranged, evacuation supplies, adaptive equipment and medications accompany individual.
Individual Signature	Date
SL Staff Signature	Date
WSC Signature	Date

These are the most important supplies during a disaster. Stock up from June through Dec and store in a water-resistant container. Add individual-specific items, as needed. Replenish as needed, especially during hurricane season.

Modified from the Federal Emergency Management Agency dpattach 06-04
DISASTER SUPPLIES	FIRST AID KIT	EVACUATION SUPPLIES
ITEM	HOW MUCH	ITEM	ITEM
Prescription medications	2-week supply	gauze rolls	Bedding – pillows, blankets, sleeping bags/air mattress
Non-perishable/special dietary food	2-week supply	bandages	Extra clothing, shoes, eyeglasses
Drinking water/containers	1 gallon per person, per day (minimum 3 days)	neosporin	Folding chairs, lawn chairs/cots
Flashlight	1 per person with 7 sets of batteries	antiseptic	Personal hygiene items (toothpaste, toothbrush, deodorant, etc)
Portable Radio	1 with 7 sets of batteries	tape	Quiet games, books, cards, favorite toys for children
Mosquito repellant/citronella candles	2 week supply	compresses	Important papers (driver license, special medical information, insurance policies, property inventories, contact information, etc)
Fire extinguisher	1 small canister, ABC type	aspirin and non-aspirin pain reliever	Adaptive equipment, as needed
Instant tire sealer	1 kit	anti-diarrhea medication
Whistle/distress flag	1	antacid
Cooler	2 (1 for ice, 1 for food)	Syrup of Ipecac (used to induce vomiting if advised by the Poison Control Center)
Plastic trash bags	roll or box	Wooden matches
Water purification kit	1 (tablets, plain chlorine, iodine)
Cleanup supplies	mop, buckets, towels, disinfectant
Camera and film	1
Non-electric can opener	1
Extra batteries	for flashlights, lamps, radio, etc
Garbage can/bucket with tight fitting lid	1 for emergency toilet
Toilet paper, paper towels, towelettes	package of each
Infant necessities	2-week supply (sterile water, diapers, ready formula, bottles)
Plastic tarp, screening, tools, nails, etc	1 tarp, 1 tool box