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Neighbor/Local Government Agency Phone Number Address



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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  
Inventory of household goods (with photos & serial numbers)  
Insurance papers  
Immunization records

· Allergies

· Medications

Bank and credit card numbers  
Emergency contact list (phone/address/email)  
Local map and emergency shelter locations  
Pet information  




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 Veterinarian and Name of Local Animal Shelter:

Name of Veterinarian Address Phone Email
Name of Local Animal Shelter Address Phone Email


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

Name Address Phone Email




Special Needs Assistance

Special needs assistance organization in community.

Name Address Phone Email


Register with your local office of emergency services or fire department.

Name Address Phone Email


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

Name Special Help Needed 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. _____




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

Certification Date of Completion Date of Renewal




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

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

Home go bag _____

Pet go bag _____

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

Car go bag – 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 all of the basic items you have and list additional specialty items you have on hand:


Change water every 6 months.

On Hand Need to Acquire Next water change _____________ (date)
Two quarts of water daily for drinking for each person in your household      
One gallon/week supply of water stored for sanitary and cooking needs for your household.      
Additional Specialty Items: On Hand Need to Acquire Next water change _____________ (date)
Extra two quarts of water daily for children, nursing mothers, and those who are ill and need more.      

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.

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