DHHS FAMILY DISASTER PLAN

Note: It is important to store this document in a secure location to reduce the risk of losing personalinformation that could lead to possible ID theft and fraud.In addition, this document should be stored in a water tight container and on a computer disk.

C o v e r p h o t o g r a p h s a p p e a r c o u r t e s y o f F E M A .

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

About your Family Disaster PlanThis booklet is a plan template and is intended to give you a format andpossible suggestions about information you might want to include in a

needs or requirements.

making future corrections to information contained in the document.

Keep this plan updated with current and correct information.

Last update: Next update:Update and review plan:

2

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Table of Contents

Household Members and Pets Inventory 4

Household Information 5

Emergency Numbers 5

Utility and Service Contracts 6

Insurance and Other Information 6

Family/Friends/Neighbors and Out of Area Contact Information 7

Work and School Contacts 8

Reunion Information 9

Important Notes and Procedures 9

Medication List 10

Pharmacy/Doctors/Specialists 11

Home Layout and Design 12

Utility Control 14

3

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Household MembersHousehold Members Relation/Birthdate Social Security

Pets Pet Rabies Vaccination # Vet name & number

4

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Household InformationHome Address: _____________________________________________________________________________

Phone1:______________________________________Phone2_______________________________________

E-mail:1____________________________________________________________________________________

E-mail:2____________________________________________________________________________________

Car Information:

Car 1: Make ______________/ Model _____________/ Year ___________ /License #__________________

Car 2: Make ______________/ Model _____________/ Year ___________ /License #__________________

Car 3: Make ______________/ Model _____________/ Year ___________ /License #__________________

Emergency Numbers

CALL 911 FOR EMERGENCY Note: After a disaster, 911 may not be working. Use the numbers you listed below.

Doctor # 1___________________________________________________________________________

Doctor # 2___________________________________________________________________________

Doctor # 3___________________________________________________________________________

Fire Number_________________________________________________________________________

Police Number_______________________________________________________________________

Ambulance Number__________________________________________________________________

Poison Control Number________________________________________________________________

Hospital Emergency Room Number_____________________________________________________

Name/Number #1____________________________________________________________________

Name/Number #2____________________________________________________________________

Name/Number #3____________________________________________________________________

Name/Number #4____________________________________________________________________

Name/Number #5____________________________________________________________________

Name/Number #6____________________________________________________________________

5

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

ContactsUtility and Service ContactsOrganization NameWater/Sewer

Address Contact

Note Phone

Organization NameElectric

Address Contact

Note Phone

Organization NameGas

Address Contact

Note Phone

Organization NamePhone/cable

Address Contact

Note Phone

Organization NameHome Medical

Address Contact

Note Phone

Insurance/Other Information (health, auto, home, and life)Name Policy#/Other Information Phone

6

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

ContactsFamily/Friends/NeighborsName Address/Physical

Location to HomePhone E-mail Address Cell phone

Number

Hm./Wk. Phone

Hm./Wk. Phone

Hm./Wk. Phone

Hm./Wk. Phone

Out-of-Area Contact #1Name Home Address Home Phone E-mail Address

Work Address Work Phone Cell Phone Number

Out-of-Area Contact #2Name Home Address Home Phone E-mail Address

Work Address Work Phone Cell Phone Number

7

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

ContactsWork, School, and Other ContactsHousehold Member Name Work/School/Other Disaster Procedures*

Address

Phone

Household Member Name Work/School/Other Disaster Procedures*

Address

Phone

Household Member Name Work/School/Other Disaster Procedures*

Address

Phone

Household Member Name Work/School/Other Disaster Procedures*

Address

Phone

Household Member Name Work/School/Other Disaster Procedures*

Address

Phone

Household Member Name Work/School/Other Disaster Procedures*

Address

Phone

8

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

ProceduresReunion ProceduresIn or Around House/Apartment Inside House/Apartment

Outside House/Apartment

When Family is Not Home Priority Location

(Leave note in a designated place whereyou will be: i.e., neighbor, relative, park,school, shelter, etc.)

Important Notes and Procedures

9

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Medication ListUser’s Name Medication Name Dosage/Frequency Reason for Taking

Doctor Prescription # Date Started/Ending Locationof Medicine

User’s Name Medication Name Dosage/Frequency Reason for Taking

Doctor Prescription # Date Started/Ending Locationof Medicine

User’s Name Medication Name Dosage/Frequency Reason for Taking

Doctor Prescription # Date Started/Ending Locationof Medicine

User’s Name Medication Name Dosage/Frequency Reason for Taking

Doctor Prescription # Date Started/Ending Locationof Medicine

-

Last Update for this page:_______________

10

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Pharmacy/Doctors/SpecialistsPharmacist Name(s) Pharmacy Name Phone/Address

Pharmacy Name Phone/Address

Specialist Name Area of Concern Phone

Organization Address

Specialist Name Area of Concern Phone

Organization Address

Allergies to Medications Person’s Name Person’s Name

Medication Medication

Health/DisabilityInformation

Special Needs, Equipment,and Supplies

Last Update for this page:_______________

11

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Pharmacy/Doctors/Specialists cont.

Allergies to Medications Person’s Name Person’s Name

Medication Medication

Health/DisabilityInformation

Special Needs, Equipment,and Supplies

Allergies to Medications Person’s Name Person’s Name

Medication Medication

Health/DisabilityInformation

Special Needs, Equipment,and Supplies

12

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Home Layout/Diagram

Draw a layout of your home. Make sure you include locations of utility

13

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Utility Control

Electricity:

1. Turn off smaller breakers one by one2. Flip the “main” breaker last

Water:

turn it to your left.

Gas:IMPORTANT – Only turn off your gas at the meter if you smell gas!

quarter turn valve that is on the pipe that feeds into the gas meter. Turn it one

once you do this you cannot turn the gas back on to the house without the util-ity company.

Propane: If you live in an area that uses outdoor propane or LPG you will

regular turn knob or a quarter turn valve. Turn the knob to your right to shut

14

N . C . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s / Fa m i l y D i s a s t e r P l a n

Disaster Supply KitWater - at least 1 gallon daily per person for 3 to 7 days

• non-perishable packaged or canned food / juices

Food - at least enough for 3 to 7 days

• foods for infants or the elderly

• snack foods

• non-electric can opener

• cooking tools / fuel

• paper plates / plastic utensils

Clothing - seasonal / rain gear/ sturdy shoes

First Aid Kit / Medicines / Prescription Drugs

Special Items - for babies and the elderly

Toiletries / Hygiene items / Moisture wipes

Flashlight / Batteries

Radio - Battery operated and NOAA weather radio

Cash (with some small bills)

Keys

Important documents - in a waterproof container

or watertight resealable plastic bag

Tools - keep a set with you during the storm

Pet care items

• ample supply of food and water

• a carrier or cage

• muzzle and leash

15

 

        N

 

 

 

 

 

 

N.C. Department

R

F

R

N

Im

L (E

F (A

of Health and H

ReadyNC

www.r

FEMA

www.f

Red Cross

www.r

NC Commiss

www.v

mportant N

Local DepartmEmergency fo

FEMA: _____Apply for disa

Human Services /

readync.org

fema.gov

redcross.org

sion on Volu

volunteernc.

Numbers to c

ment of Sociaood stamps, em

___________aster funds)

State of No

N.C. DHHS i

/ Family Disaste

unteerism &

org

contact afte

al Services: _mergency Me

____________

orth Carolina * Deww

is an equal opportu

er Plan

& Commun

er a disaster

___________edicaid, emerg

___________

epartment of Healtww.ncdhhs.gov unity employer and

nity Service

r:

____________gency financi

____________

 

th and Human Serv

d provider. Revise

____________ial assistance)

___________

rvices

ed 09/11

___________)

___________

16 

_____

_____