Family Members / Household Contact Info: - Christian County …



The FORMTEXT ????? Family Disaster Plan Date: FORMTEXT ?????Physical Household Address FORMTEXT ?????Contents TOC \o "1-3" \h \z \u Family Members / Household Contact Info: PAGEREF _Toc501024590 \h 2The disasters that are likely to affect our household are: PAGEREF _Toc501024591 \h 2Evacuations / Travel Plans PAGEREF _Toc501024592 \h 2Emergency Contacts PAGEREF _Toc501024593 \h 3If at school/daycare, our children will be evacuated to: PAGEREF _Toc501024594 \h 3Nearest Tornado Safe Rooms PAGEREF _Toc501024595 \h 3Our plan for people in our household with a disability or special need is: PAGEREF _Toc501024596 \h 3Pre-Disaster Activities PAGEREF _Toc501024597 \h 4Family Member Responsibilities: PAGEREF _Toc501024598 \h 4Home Disaster Kit Contents: PAGEREF _Toc501024599 \h 5First Aid Kit Contents: PAGEREF _Toc501024600 \h 6Evacuation Kit Contents: (to go to a shelter) PAGEREF _Toc501024601 \h 6Pet Evacuation Kit PAGEREF _Toc501024602 \h 7Vehicle Emergency Kit PAGEREF _Toc501024603 \h 7Information Notebook Contents PAGEREF _Toc501024604 \h 7Family Medicine Information PAGEREF _Toc501024605 \h 8Preparedness Activities PAGEREF _Toc501024606 \h 9General Preparedness Activities PAGEREF _Toc501024607 \h 9Fire Safety Preparedness PAGEREF _Toc501024608 \h 9Tornado Preparedness PAGEREF _Toc501024609 \h 9Winter Weather / Ice Storm Preparedness PAGEREF _Toc501024610 \h 10Severe Weather / Thunderstorm Preparedness PAGEREF _Toc501024611 \h 10Flood / Flash Flood Preparedness PAGEREF _Toc501024612 \h 10Power Outage Preparedness PAGEREF _Toc501024613 \h 11Terrorism Preparedness PAGEREF _Toc501024614 \h 11Communication Plan PAGEREF _Toc501024615 \h 12Back-Up Phone Database PAGEREF _Toc501024616 \h 14Completed Drills / Exercises / Schedule PAGEREF _Toc501024617 \h 15Disaster Kit Maintenance PAGEREF _Toc501024618 \h 16Editing Instructions PAGEREF _Toc501024619 \h 17Type information into the gray shaded boxes.Family Members / Household Contact Info: NameHome PhoneCell PhoneEmail** FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2150971202900**Main “In case of emergency” contact personPet(s) Info:NameTypeColorMicro-ChipRegistration # FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ?????The disasters that are likely to affect our household are: FORMCHECKBOX Tornado FORMCHECKBOX Severe Storms FORMCHECKBOX Ice Storm FORMCHECKBOX Flash Flood FORMCHECKBOX River Flooding FORMCHECKBOX Wildfires FORMCHECKBOX Earthquake FORMCHECKBOX Winter Storm FORMCHECKBOX Heatwave FORMCHECKBOX Drought FORMCHECKBOX Pandemic (flu) FORMCHECKBOX Sinkhole FORMCHECKBOX House Fire FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Evacuations / Travel PlansWhat are the escape routes from our home? (know at least 2 ways to get out of your neighborhood)1 FORMTEXT ?????2 FORMTEXT ?????3 FORMTEXT ??????If separated during an emergency, what is our meeting place in our neighborhood? FORMTEXT ?????If we cannot return home or are asked to evacuate, what is our meeting place outside of our neighborhood? FORMTEXT ?????If we have to leave the house because it is unsafe (fire, collapse, smoke, etc.) our meeting place near the house is? FORMTEXT ??????Emergency ContactsMain Out of the Area ContactNameHome PhoneCell PhoneEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????0116200Alternate Out of the Area Contact:NameHome PhoneCell PhoneEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????If at school/daycare, our children will be evacuated to:???Child’s NameEvacuation SitePickup Procedure FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Nearest Tornado Safe RoomsName of FacilityAddressMinutes from our houseDo they accept pets? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Our plan for people in our household with a disability or special need is:(include person responsible, any special medications or equipment needed, etc.)Person’s NamePlan FORMTEXT ????? FORMTEXT ?????Medical Equipment Needed FORMTEXT ?????Medications Needed FORMTEXT ?????Location of Medications FORMTEXT ?????Person’s NamePlan FORMTEXT ????? FORMTEXT ?????Medical Equipment Needed FORMTEXT ?????Medications Needed FORMTEXT ?????Location of Medications FORMTEXT ?????Person’s NamePlan FORMTEXT ????? FORMTEXT ?????Medical Equipment Needed FORMTEXT ?????Medications Needed FORMTEXT ?????Location of Medications FORMTEXT ?????Pre-Disaster ActivitiesFamily Member Responsibilities:TaskDescriptionFamily Member ResponsibleHome Disaster KitStock the disaster kit and make sure it is up to date. See recommended list below. FORMTEXT ?????Evacuation KitStock the Evacuation kit and make sure it is accessible and ready to go at a moments notice. ?Include items you might want to take to an evacuation shelter. See recommended list below. FORMTEXT ?????First Aid KitStock the First Aid kit and make sure it is up to date. See recommended list below. FORMTEXT ?????Pet Evacuation KitStock the pet evacuation kit and make sure it is up to date. Be sure to include pet supplies in your Home Disaster Kit also. See recommended list below. FORMTEXT ?????Vehicle Emergency KitStock the Vehicle Emergency Kit and make sure it is up to date and in the vehicle at all times. See recommended list belowInformation AccessMake sure that the NOAA Radio is programmed and has fresh batteries. Ensure that all family members have an up to date copy of this plan. Make sure all members have at least 2 ways to get emergency notifications (Swift 911 App, local media alert apps, etc). Make sure there is a battery powered radio both disaster kits. Make sure every family member has a copy of this plan. FORMTEXT ?????Family Medical / Medicine InformationKeep current lists of family members medications and medical information. Make sure these lists are in the evacuation kit. Include medication list, doctors contact info, medical alerts and any allergic reaction information. See template below. FORMTEXT ?????Financial InformationObtain copies of bank statements and keep some cash in the disaster kits in the event ATMs and credit cards do not work due to power outages.??Bring copies of utility bills as proof of residence in applying for assistance from Red Cross or FEMA. FORMTEXT ?????Pet InformationKeep a phone list of pet‐friendly motels and animal shelters and Vets and keep in the pet disaster kit. FORMTEXT ?????Information NotebookInclude a 3-ring binder to your kit to store reference material in. Include: how to purify water, first aid instructions, NOAA radio frequencies, pet first aid, etc. Keep an electronic copy as well as important documents on a jump drive stored in the disaster kit. FORMTEXT ?????Smoke, Carbon Monoxide Detectors, Fire ExtinguishersCheck each piece of equipment monthly to ensure proper operation, check and replace batteries as needed. Have the fire extinguishers tested annually. FORMTEXT ?????GeneratorCheck and start the generator monthly to ensure proper operation. Check oil level, filters and fuel supply. Refer to manufacturers recommendations on long term fuel storage in the fuel tank. FORMTEXT ?????Back to Top of DocumentHome Disaster Kit Contents: FORMCHECKBOX Water, Stored in Gal Jugs for cleaning, sanitation, food prep (1 gal per person per day) 4 days preferred) FORMCHECKBOX Water, smaller bottles for drinking (1 gal per person per day) FORMCHECKBOX Food (at least a four-day supply of non-perishable food) FORMCHECKBOX Garbage Bags FORMCHECKBOX Battery-powered or hand crank radio FORMCHECKBOX Basic tools (hammer, screwdrivers, pliers, wrench, crowbar) FORMCHECKBOX NOAA Weather Radio FORMCHECKBOX Tool to turn of utilities: gas, water FORMCHECKBOX Flashlight with spare batteries FORMCHECKBOX Manual can opener FORMCHECKBOX First Aid Kit FORMCHECKBOX Local Paper Maps FORMCHECKBOX Whistle FORMCHECKBOX Solar powered cell phone charger FORMCHECKBOX Phone Chargers FORMCHECKBOX Duct Tape FORMCHECKBOX N-95 Dust Masks FORMCHECKBOX Toilet paper FORMCHECKBOX Family Medical / Medicine List FORMCHECKBOX Baby / Small Children’s Supplies (formula, toys, etc) FORMCHECKBOX Financial Information FORMCHECKBOX Blankets FORMCHECKBOX Pet Information FORMCHECKBOX Change of Clothes FORMCHECKBOX Medications FORMCHECKBOX Moist towelettes FORMCHECKBOX Cash FORMCHECKBOX Feminine Supplies FORMCHECKBOX Paper and Pencil FORMCHECKBOX Rain Poncho’s FORMCHECKBOX Chlorine Bleach (purify water) FORMCHECKBOX Medicine Dropper (measure bleach for water) FORMCHECKBOX Information Notebook FORMCHECKBOX Spare reading glasses FORMCHECKBOX Contact lenses and solutions FORMCHECKBOX Pet Food FORMCHECKBOX Mess Kit (paper plates, utensils, paper towels, etc) FORMCHECKBOX Vitamins FORMCHECKBOX Knife FORMCHECKBOX Multi-Tool FORMCHECKBOX Leather Work Gloves FORMCHECKBOX Winter Clothes (gloves, knit hat, etc.) FORMCHECKBOX Roll of Plastic Sheeting FORMCHECKBOX Hand Sanitizer FORMCHECKBOX Pepper Spray FORMCHECKBOX Candles FORMCHECKBOX FORMCHECKBOX Fire starter (matches, lighter, etc) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Optional Items FORMCHECKBOX Lantern FORMCHECKBOX Tarps FORMCHECKBOX Two Way Radios (FRS Radios) FORMCHECKBOX Books, Games, Puzzles FORMCHECKBOX Small Cooking Stove with Fuel FORMCHECKBOX Utility Rope FORMCHECKBOX Sleeping Bags FORMCHECKBOX Paracord FORMCHECKBOX Light Sticks FORMCHECKBOX Fire Starter (matches, lighters, etc) FORMCHECKBOX ZipLoc Bags FORMCHECKBOX Bandana’s FORMCHECKBOX Super Glue FORMCHECKBOX Water Purification Tablets FORMCHECKBOX Hatchet FORMCHECKBOX Chainsaw FORMCHECKBOX Small Water Filter FORMCHECKBOX Extra Firewood FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? HYPERLINK \l "Top" Back to Top of DocumentFirst Aid Kit Contents: FORMCHECKBOX 2-inch sterile gauze pads (12+) FORMCHECKBOX Tweezers FORMCHECKBOX 4-inch sterile gauze pads (12+) FORMCHECKBOX Needle FORMCHECKBOX Hypoallergenic adhesive tape (2) FORMCHECKBOX Moistened towelettes FORMCHECKBOX Triangular bandages (3) FORMCHECKBOX Antiseptic FORMCHECKBOX 2-inch sterile roller bandages (6+ rolls) FORMCHECKBOX Thermometer FORMCHECKBOX 3-inch sterile roller bandages (6+ rolls) FORMCHECKBOX Ice Packs FORMCHECKBOX Scissors FORMCHECKBOX Tube of petroleum jelly or other lubricant FORMCHECKBOX Assorted sizes of safety pins FORMCHECKBOX Latex gloves (2 pair) FORMCHECKBOX Cleansing agent/soap FORMCHECKBOX Sunscreen FORMCHECKBOX Hydrocortisone FORMCHECKBOX Bug Spray FORMCHECKBOX Ibuprofen / Tylenol FORMCHECKBOX Calamine Lotion FORMCHECKBOX Benadryl FORMCHECKBOX Neosporin FORMCHECKBOX Antacids FORMCHECKBOX Saline Solution FORMCHECKBOX Baby Wipes FORMCHECKBOX Large Trauma Pads (6+) FORMCHECKBOX Q-Tips FORMCHECKBOX Emergency Blankets FORMCHECKBOX Imodium / Pepto-Bismol FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Evacuation Kit Contents: (to go to a Long-Term Shelter, consider a kit for each family member) FORMCHECKBOX Map marked with at least two evacuation routes FORMCHECKBOX Change of clothing FORMCHECKBOX Prescriptions or special medications FORMCHECKBOX Extra eyeglasses or contact lenses FORMCHECKBOX An extra set of car keys, credit cards, cash FORMCHECKBOX First aid kit FORMCHECKBOX Flashlight FORMCHECKBOX Battery-powered radio and extra batteries FORMCHECKBOX Toilet Paper FORMCHECKBOX Copies of important documents (birth certificates, passports, License, SS # etc.) FORMCHECKBOX Pet Disaster Kit FORMCHECKBOX Personal computer information on a jump drive FORMCHECKBOX Chargers for cell phones, laptops, etc. FORMCHECKBOX Personal Care Items: tooth brush, deodorant, etc. FORMCHECKBOX Baby / Small Children’s Supplies (formula, toys, etc) FORMCHECKBOX Family Medical / Medicine List FORMCHECKBOX NOAA Weather Radio FORMCHECKBOX Financial Information FORMCHECKBOX Paper and Pencil FORMCHECKBOX Feminine Supplies FORMCHECKBOX Any special dietary needs or food FORMCHECKBOX Any Special Medical Equipment/extra batteries FORMCHECKBOX Emergency Contact Lists FORMCHECKBOX Bedding (sleeping bags or warm blankets) FORMCHECKBOX FORMTEXT ????? Who is responsible for grabbing the kit? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Pet Evacuation Kit FORMCHECKBOX Food (at least 4 days’ supply) FORMCHECKBOX Water (at least 4 days’ supply) FORMCHECKBOX Medications FORMCHECKBOX Medical records FORMCHECKBOX Cat Litter Box, Litter, Litter Scoop FORMCHECKBOX Garbage Bags (collect pet waste) FORMCHECKBOX Leash / Harness FORMCHECKBOX Pet Carrier FORMCHECKBOX Current Photo’s / Descriptions of pets FORMCHECKBOX Vet Contact info FORMCHECKBOX Grooming Items FORMCHECKBOX Bleach FORMCHECKBOX Paper Towels FORMCHECKBOX Micro Chip Information FORMCHECKBOX Food and Water Dishes FORMCHECKBOX Flea and tick medication FORMCHECKBOX Toys FORMCHECKBOX Pet First Aid Book FORMCHECKBOX Pet First Aid Kit FORMCHECKBOX Latex Gloves FORMCHECKBOX Treats FORMCHECKBOX Bedding FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Vehicle Emergency Kit FORMCHECKBOX Jumper cables FORMCHECKBOX Flares or reflective triangle FORMCHECKBOX Ice Scraper FORMCHECKBOX Cell Phone Charger FORMCHECKBOX Cat Litter or Sand for traction FORMCHECKBOX Can of Ice Melt for door locks and handles FORMCHECKBOX Blanket FORMCHECKBOX Warm clothes, stocking cap, winter boots, gloves FORMCHECKBOX Small First Aid Kit FORMCHECKBOX Fire Extinguisher FORMCHECKBOX Tire Gauge FORMCHECKBOX Foam Tire Sealant FORMCHECKBOX Flashlight and extra batteries FORMCHECKBOX Duct Tape FORMCHECKBOX Drinking water FORMCHECKBOX Snacks FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Information Notebook Contents FORMCHECKBOX A copy of this plan FORMCHECKBOX Insurance information FORMCHECKBOX Info on how to sanitize water FORMCHECKBOX Informational Web Sites FORMCHECKBOX First Aid Manuals FORMCHECKBOX Copies of titles, registrations FORMCHECKBOX Bank Account Information FORMCHECKBOX Identification / Driver’s License / SS# FORMCHECKBOX Immunization records FORMCHECKBOX Birth Certificates FORMCHECKBOX Maps of the area FORMCHECKBOX Pet‐friendly motels and animal shelters FORMCHECKBOX Names and addresses of close relatives FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????926679164846800Family Medicine InformationNameMedicationWhen Med is takenDoctor4-day supply in Disaster Kit? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMDROPDOWN Family Medical InformationNameAgeMedical IssueDoctor FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Back to Top of DocumentPreparedness ActivitiesGeneral Preparedness Activities FORMCHECKBOX Does everyone have a copy of this plan? FORMCHECKBOX Have we practiced our Evacuation Drill? FORMCHECKBOX Have we practiced our Fire Drill? FORMCHECKBOX Does everyone know how to use 911? FORMCHECKBOX Do we have adequate Insurance Coverage? Do we need Flood Insurance? FORMCHECKBOX Do we have smoke detectors installed? FORMCHECKBOX Do we know how to shut the power off if needed? FORMCHECKBOX Have we checked the batteries in the smoke detectors and tested them monthly FORMCHECKBOX We have a working carbon monoxide detector? FORMCHECKBOX FORMCHECKBOX Chemicals stored out of reach of children FORMCHECKBOX Tall, heavy furniture secured to wall? FORMCHECKBOX Do we know how to shut off the gas and water to our house? FORMCHECKBOX Is our water heater strapped to the wall to prevent tip over? FORMCHECKBOX Do we have Carbon Monoxide Detectors installed? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Fire Safety Preparedness FORMCHECKBOX Do we have fire extinguishers? ABC type FORMCHECKBOX Flammable liquids stored properly? FORMCHECKBOX Fire Extinguishers up to date and working? FORMCHECKBOX Have we replaced frayed or cracked extension and appliance cords? FORMCHECKBOX Does everyone know where to meet outside if we have a fire and have to get out? FORMCHECKBOX Are our important papers and valuables stored in afire-proof safe or cabinet? FORMCHECKBOX Everyone has two ways out of the house in case of a fire? FORMCHECKBOX Combustible materials are not stored near the furnace, hot water heater or space heaters? FORMCHECKBOX Our chimney / flue pipes have been cleaned and checked? FORMCHECKBOX Utility shut off tools are stored in an accessible location? FORMCHECKBOX Is our house number clearly visible outside? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Tornado Preparedness FORMCHECKBOX Do we know where to go inside the house in the event of a tornado? FORMCHECKBOX Can we stay in the house if there is a tornado, or do we go to the nearest Safe Room? FORMCHECKBOX If we have to go to a Safe Room tornado shelter, do we have a “kit” prepared to take with us? Toys, baby needs, water, radio, phone charger, etc. FORMCHECKBOX If we have to go to the nearest Safe Room, have we practiced getting there and know how long it will take. FORMCHECKBOX Do we know the opening procedures for the Safe Room that we will be going to? FORMCHECKBOX Do we have a NOAA weather alert radio in the home? Have we checked it monthly? FORMCHECKBOX Does everyone in the family have a way to receive weather alerts and warnings? FORMCHECKBOX Does everyone in the home know the difference between watches and warning issued by NOAA? FORMCHECKBOX Have we practiced our “in home” tornado drill? FORMCHECKBOX Does someone in the family watch the weather forecast daily? FORMCHECKBOX Is our disaster kit stored near the tornado shelter in our home? FORMCHECKBOX Is there a battery powered radio in our tornado shelter location? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Winter Weather / Ice Storm Preparedness FORMCHECKBOX Our home is well insulated and we have weather stripping around our doors and windows FORMCHECKBOX Do we have a working carbon monoxide detector? FORMCHECKBOX Our vehicles are winterized and always have more than a half tank of gas? FORMCHECKBOX Our vehicles have an emergency kit? FORMCHECKBOX Are tree limbs trimmed away from our house / power lines? FORMCHECKBOX Do we add extra food items to our disaster kit in the winter in case we loose power for several days? FORMCHECKBOX Do we have plenty of batteries on hand in case we loose power for several days? FORMCHECKBOX Do we have an alternate lighting source? Solar lights, candles, lanterns, etc. FORMCHECKBOX Do we have shovels for snow removal? FORMCHECKBOX Do we have extra bags of Ice Melt? FORMCHECKBOX Do we have an emergency heat source? FORMCHECKBOX Do we have a way to cook without electricity? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Severe Weather / Thunderstorm Preparedness FORMCHECKBOX We removed dead or rotting trees and branches that could fall and cause injury or damage FORMCHECKBOX Outdoor objects are secured that could blow away or cause damage. FORMCHECKBOX Everyone knows the difference between “Watch and Warnings” issued by NOAA FORMCHECKBOX We have a NOAA weather radio. FORMCHECKBOX Everyone has at least 2 ways to receive alerts? FORMCHECKBOX Everyone knows to stay away from windows during the storm and to stay indoors? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Flood / Flash Flood Preparedness FORMCHECKBOX Do we need to purchase Flood Insurance? FORMCHECKBOX Have we checked with local officials / neighbors to see if our property is prone to flooding? FORMCHECKBOX Everyone in the family knows not to drive thru flooded roadways? FORMCHECKBOX If our property is prone to flooding, do we have a plan to elevate important items, unplug electrical appliances before water comes into the house? FORMCHECKBOX Are the roads to our house prone to flooding/ FORMCHECKBOX If the roads are impassable, do we have a different way to get home, or someplace to stay until it is safe to return home? FORMCHECKBOX Are our important papers kept in a water proof container? FORMCHECKBOX Are there things we can do to reduce flooding potential? Berms, ditches, culverts, etc? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Power Outage Preparedness FORMCHECKBOX Do we have coolers on hand to keep food from spoiling? FORMCHECKBOX Do we have 2litre bottles with frozen water stored in the freezer to put in the coolers? FORMCHECKBOX Do we have a thermometer to check the temperature of our food? FORMCHECKBOX Do we keep our vehicle gas tanks full of gas? FORMCHECKBOX Do we need to purchase a small generator? FORMCHECKBOX Do we have plenty of spare batteries FORMCHECKBOX Do we have an alternate way of heating the home? FORMCHECKBOX Do we have an alternate way of cooking? FORMCHECKBOX Do we have an alternate way of lighting the home? FORMCHECKBOX Does everyone know the risks of Carbon Monoxide poisoning? FORMCHECKBOX Do we have an alternate way of charging our phones? FORMCHECKBOX Does everyone know where the emergency release on the garage door is? FORMCHECKBOX Do we have backup power for any special medical equipment in the home? FORMCHECKBOX Do we have a way to store water to flush the toilet in case the water supply is cut off? (bath tub) FORMCHECKBOX Do we have plenty of paper plates, plastic cups, plastic utensils so we don’t wash dishes? FORMCHECKBOX Do we have plenty of “entertainment” on hand: board games, puzzles, books, etc. FORMCHECKBOX Do we have cash on hand in case the ATM’s don’t work? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Terrorism Preparedness FORMCHECKBOX Do we know where the school’s evacuation sites are and how we will pick up our children if activated? FORMCHECKBOX Does everyone know the “Shelter in Place” procedures? FORMCHECKBOX Do we have a room that we can seal off for “Shelter in Place” in case of a chemical leak/spill? FORMCHECKBOX If the threat of Nuclear War is closer at hand, can we increase our Disaster Supply Kit to a 2-week supply quickly and easily? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ????? FORMCHECKBOX FORMTEXT ?????Back to Top of DocumentCommunication PlanUsed when the emergency or event initially happens.Used when family is dispersed over a large area, more than 1 mile from homePrimaryCell PhoneVoice: naturally the first choice of communication to give and receive the most accurate information with the most contentText: Text messages sometimes will go thru when voice calls will not due to overloaded network traffic. Almost as good as voice, but content suffers somewhat due to the fact that you are not having a normal conversation. Text messaging is more covert. AlternateUse someone else’s phone to try to contact the person Use someone else’s phone that is on a different carrier. Try to contact another person. If that works, have that person try to contact the family member you are trying to contact and relay information.Land Line telephones:If cell towers are down, landline phones can be used. There are not many pay phones available now. Entering a business and asking permission to use their phone will work sometimes. ContingencyOut of state contact: If none of the above work, and there is an active widespread emergency (large tornado, large earthquake, terrorism, widespread power outage, etc.), you should contact the out of state contacts.If all family members cannot contact each other, or one or more cannot be contacted, each one should call BOTH of the out of state contacts and let them know what is happening, their status and what they will be doing or where they are headed to. Then the out of state contact can let each family member know what is happening and relay any messages as the others call in. Primary out of state contact: FORMTEXT ????? (name)First try a voice phone call to FORMTEXT ????? (phone number)If voice doesn’t work, try text message. If the call goes thru but no answer, leave a message and then send a detailed text message.Secondary out of state contact: FORMTEXT ????? (name)First try a voice phone call to FORMTEXT ????? (phone number)If voice doesn’t work, try text message. If the call goes thru but no answer, leave a message and then send a detailed text message. FORMTEXT ????? (names of family, i.e. Dad and Mom) will contact the out of state contact on every half hour (1:30, 2:30, etc). The FORMTEXT ????? (names of family, i.e. the kids) will contact the out of state contact on top of the hour (1:00, 2:00, etc) until we all get home. Back to Top of DocumentItems to consider for Long Term Preparedness and Self Sufficiency FORMCHECKBOX Chainsaw FORMCHECKBOX Camp Coffee Pot FORMCHECKBOX Cooking Grate (cook over an open fire) FORMCHECKBOX Camp Shower FORMCHECKBOX Dutch Oven FORMCHECKBOX Camp Stove FORMCHECKBOX Fire Starting Materials/Tinder FORMCHECKBOX Canned food FORMCHECKBOX Hand powered kitchen utensils FORMCHECKBOX Charcoal, lighter fluid FORMCHECKBOX Hatchet / Ax FORMCHECKBOX Coleman Lanterns FORMCHECKBOX Home Canned Food FORMCHECKBOX Freeze Dried Food FORMCHECKBOX Oil Lamps / Lamp Oil FORMCHECKBOX FRS Two Way Radios FORMCHECKBOX Self Defense Items FORMCHECKBOX Garden FORMCHECKBOX Solar Power, Panels, Batteries, Charge Controllers FORMCHECKBOX Small personal water filters FORMCHECKBOX Water Purification Tablets FORMCHECKBOX Rain Water Collection System FORMCHECKBOX Wood Stove FORMCHECKBOX Tent FORMCHECKBOX Firewood FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Back to Top of DocumentBack-Up Phone DatabaseList of important phone numbers in case the contacts in you phone is not accessible NameHome PhoneCell PhoneEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Back to Top of DocumentCompleted Drills / Exercises (enter the dates when completed)DrillDateDateDateDateDateFire / Unsafe Building Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Evacuation to a Long-Term Shelter Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Evacuation to a FEMA Safe Room Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Flood Evacuation Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Shelter in Place Tornado Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Shelter in Place Hazardous Materials Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Communication Drill FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Each Drill should be practiced at least twice a year.Schedule of Drills and ExercisesJanuaryFebruaryMarch AprilMayJune FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????JulyAugustSeptemberOctoberNovemberDecember FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Disaster Kit MaintenanceKitDate UpdatedDate UpdatedDate UpdatedDate UpdatedDate UpdatedHome Disaster Kit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Evacuation Kit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????First Aid Kit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Pet Evacuation Kit FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vehicle Kit 1 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vehicle Kit 2 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vehicle Kit 3 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Vehicle Kit 4 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Informational Notebook FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medication Information FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Family Medical Information FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Smoke Detectors FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Fire Extinguishers FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Carbon Monoxide Detectors FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Chimney / flue pipe inspected FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Generator FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Check / replace batteries, check for expired items, update information as needed, replenish used stock. Back to Top of DocumentEditing Instructions, to add more form fields, more rows, etc the “Developer Tab” has to be showing. Most of the time, the “Developer Tab” on the menu is not visible. To make the “Developer Tab” visible:Click the File tab.Click Options.Click Customize Ribbon.Under Customize the Ribbon and under Main Tabs, select the Developer check box.“Unprotect” the documentClick the “Developer Tab”Click “Restrict Editing”A panel will open on the right side, click “Stop Protection”If it asks for a password, all fields are blank.Make you edits and then click “Yes, Start Enforcing Protection” in the panel on the right.Do not type in “form fields” while in editing mode, it will erase the form field.Hit “OK”. Back to Top of Document ................
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