Household Emergency Plan Template

Household Name:

Address:

Phone:
YOUR Household Emergency Plan
Table of Contents
If you have any questions Please contact Emergency Management at 801-957-4963. Household Member Info 2
Utility / Service Contract / Insurance Info 3
Keep this plan updated with current information! Relatives / Friends / Neighbors 4
Medical Info 5
Emergency Procedures 6
IN AN EMERGENCY: Household Diagram 7
General Emergency Info 8
ARC Emergency Kit Info 10
• Stay Informed! CDC Hygiene Procedures 12
 Utilize information from local radio and television sources.
 Stay in touch with your neighbors
• Know who to call /where to find help.
 Know which local officials to contact.
 Know the availability and types of local response.
 Know local emergency response resources (i.e. fire, EMS, & law enforcement).
• Know what to do if someone is hurt or sick.
 Learn first aid !
 Have emergency medical supplies on hand.
 Know where to turn for medical assistance.

Date Plan was established :

Date Plan was updated:
HOUSEHOLD MEMBER INFORMATION Last Update:

Date of Social Home & Work / Work / Other

Name
Birth Security # Cell # School School Contact #
# Address

Pet Name / Species /

Age Veterinarian Vet Contact Info Vet Address
License # / Microchip #
UTILITIES / SERVICE CONTRACT / INSURANCE INFO Last Update:

Provider Information Emergency Contact # Account Info

Water

Sewer

Electric

Gas

Telephone

Cable / Internet

Home / Renters Insurance(agency & agent)

Auto / Boat / Other Insurance(agency & agent)

 Home / Work
Name Relationship Address Email
/ Cell #s

O-T-C

O-T-C

Note: -People listed in this table should be the people you will turn to for assistance in a time of emergency. This includes relatives,
neighbors, friends, and Out-of-Town-Contacts (O-T-C)! -Identify at least two (2) out-of-town contacts. Ensure all household members
know the contact info for the O-T-Cs. If local telephone lines are overloaded, complete one call to the out-of-town contact and let them
attempt to contact others. -Identify at least two (2) friends / neighbors! Agree to check on each other. -It is suggested that all persons
listed above have a copy of this plan!
EMERGENCY CONTACTS (Relatives / Friends / Neighbors) Last Update:
 NAME

Name / Age: Name / Age: Name / Age: Name

Primary Care Doctor
(Name) Contact #
Hospital

Medication Include:
Dosage / Frequency,
Reason for Taking,
Location in household,
and Pharmacy Contact #
Medication Include:
Dosage / Frequency,
Reason for Taking,
Location in household,
and Pharmacy Contact #
Medication Include:
Dosage / Frequency,
Reason for Taking,
Location in household,
and Pharmacy Contact #
Medication Include:
Dosage / Frequency,
Reason for Taking,
Location in household,
and Pharmacy Contact #

MEDICAL INFORMATION Last update:

Note: It is good practice to keep at least seven days of vital medications and medical supplies on hand. Consult a doctor and/or
a pharmacist about medication storage.
EMERGENCY PROCEDURES: Last Update:
Household members should know emergency procedures for each other’s work, school, or other places where they regularly spend
time. Identify, discuss and document these with all household members !
Also discuss how to reunite if a disaster strikes while household members are away from the home. Make plans for where household
members should go and whom they should contact when the home is not habitable, safe or if they cannot return to the home. Refer to your
Relatives / Friends / Neighbors list (p.4).
Emergency procedures (including those needed for evacuation events and the reunification process) need to address when 1)Household
members, especially children, are away from the home, 2) How to deal with pets, and 3) Household members with disabilities.

School Emergency Procedures:

Trusted Adults

Workplace Emergency Procedures:

If we cannot enter the household:

If we cannot return to the household:

If we are not together:

HOME LAYOUT / DIAGRAM Last Update:

Draw a layout of your home. Make sure you include:

• Locations of utility shutoffs
• Safety equipment (fire extinguishers,
• Household emergency meeting / reunification (electric & gas) disaster supplies, etc.) points
GENERAL EMERGENCY SITUATION INFORMATION
Learn where and how you may be NOTIFIED of an emergency and/or hazard at http://www.countyofdane.com/emergency/warning.aspx
Identify what information you will need to make clear and appropriate decisions

Shelter – In – Place: (from the American Red Cross)

Shelter-in-place means selecting a small, interior room, with no or few windows, and taking refuge there. It does not mean sealing off your
entire home or office building. Contaminants may be released accidentally or intentionally into the environment. Should this occur,
information will be provided by local authorities via television and radio stations on how to protect you and your family. Because information
will most likely be provided on television and radio, it is important to keep a TV or radio on, even during the workday. The important thing is
for you to follow instructions of local authorities and know what to do if they advise you to shelter-in-place. If you are told to shelter-in-place,
follow these instructions:
• Close and lock all windows and exterior doors.
• If you are told there is danger of explosion, close the window shades, blinds, or curtains.
• Turn off all fans, heating and air conditioning systems.
• Close the fireplace damper.
• Get your household disaster supply kit and make sure the radio is working.
• Go to an interior room without windows that's above ground level. In the case of a chemical threat, an above-ground location is
preferable because some chemicals are heavier than air, and may seep into basements even if the windows are closed.
• Bring your pets with you, and be sure to bring additional food and water supplies for them.
• It is ideal to have a hard-wired telephone in the room you select. Call your emergency contact and have the phone available if you
need to report a life-threatening condition. Cellular telephone equipment may be overwhelmed or damaged during an emergency.
• Use duct tape and plastic sheeting (heavier than food wrap) to seal all cracks around the door and any vents into the room.
• Keep listening to your radio or television until you are told all is safe or you are told to evacuate. Local officials may call for evacuation
in specific areas at greatest risk in your community.

Remember that instructions to shelter-in-place are usually provided for durations of a few hours, not days or weeks. There is little
danger that the room in which you are taking shelter will run out of oxygen and you will suffocate.

If you are driving a vehicle and hear advice to “shelter-in-place” on the radio, take these steps:
 If you are very close to home, your office, or a public building, go there immediately and go inside. Follow the shelter-in-place
recommendations for the place you pick described above.
 If you are unable to get to a home or building quickly and safely, then pull over to the side of the road. Stop your vehicle in the safest
place possible. If it is sunny outside, it is preferable to stop under a bridge or in a shady spot, to avoid being overheated.
 Turn off the engine. Close windows and vents.
  If possible, seal the heating/air conditioning vents with duct tape.
 Listen to the radio regularly for updated advice and instructions.
 Stay where you are until you are told it is safe to get back on the road. Be aware that some roads may be closed or traffic detoured.
Follow the directions of law enforcement officials.

Local officials on the scene are the best source of information for your particular situation. Following their instructions during and
after emergencies regarding sheltering, food, water, and clean up methods is your safest choice.

Evacuation: (from FEMA)

When community evacuations become necessary, local officials provide information to the public through the media. In some
circumstances, other warning methods, such as sirens or telephone calls, also are used. Additionally, there may be circumstances under
which you and your family feel threatened or endangered and you need to leave your home, school, or workplace to avoid these situations.
The amount of time you have to leave will depend on the hazard. However, many disasters allow no time for people to gather even the most
basic necessities, which is why planning ahead is essential!

FEMA’s Evacuation Guidelines:

Prepare for disasters before they strike:

Build A Disaster Supplies Kit
There are six basics you should stock for your home in the case of an emergency:
• Water
• First Aid Supplies
• Clothing & Bedding
• Food
• Tools & Emergency Supplies Special Items

Keep the items that you would most likely need during an evacuation in an easy-to carry container. Possible containers include a large, covered trash
container, a camping backpack or a duffle bag.

Below is a comprehensive list of what should be included in your kit – recommended items are marked with an asterisk(*).
WATER
 Store water in plastic containers such as soft drink bottles. Avoid using containers that will decompose or break, such as milk cartons or glass bottles. A
normally active person needs to drink at least two quarts of water each day. Hot environments and intense physical activity can double that amount.
Children, nursing mothers, and ill people will need more.
 Store one gallon of water per person per day.
 Keep at least a three-day supply of water per person (per day per person – at least two quarts for drinking and two quarts for food preparation /
sanitation).*

FOOD
Store at least a three-day supply of nonperishable food. Select foods that require no refrigeration, preparation or cooking, and little or no water. If you must heat
food, pack a can of sterno. Select food items that are compact and lightweight. Include a selection of the following foods in your Disaster Supplies Kit:
• Ready-to-eat canned meats, fruits, and vegetables
• Canned juices
• Staples (salt, sugar, pepper, spices, etc.)
• High energy foods
• Vitamins
• Food for infants
• Comfort/stress foods

FIRST AID SUPPLIES

Assemble a first aid kit for your home and one for each car.
 (20) adhesive bandages, various sizes.
 (1) 5" x 9" sterile dressing.
 (1) conforming roller gauze bandage.
 (2) triangular bandages.
 (2) 3 x 3 sterile gauze pads.
 (2) 4 x 4 sterile gauze pads.
 (1) roll 3" cohesive bandage.

 (2) germicidal hand wipes or waterless alcohol-based hand sanitizer.

 (6) antiseptic wipes.
 (2) pair large medical grade non-latex gloves.
 Adhesive tape, 2" width.
  Anti-bacterial ointment.
 Cold pack TOOLS and EMERGENCY SUPPLIES
 Scissors (small, personal).
• Mess kits, or paper cups, plates, and plastic utensils*
 Tweezers.
 CPR breathing barrier, such as a face shield. • Emergency preparedness manual*
• Battery-operated radio and extra batteries*
Non-Prescription Drugs • Flashlight and extra batteries*
• Aspirin or non-aspirin pain reliever
• Anti-diarrhea medication
• Cash or traveler's checks, change*
• • Antacid (for stomach upset) (Continued) • Non-electric can opener, utility knife*
• Syrup of Ipecac (use to induce vomiting if advised by the Poison Control Center) • Fire extinguisher: small canister ABC type
• Laxative • Tube tent
• Pliers
• Tape
CLOTHING and BEDDING *Include at least one complete change of • Compass
clothing and footwear per person. • Matches in a waterproof container
• Sturdy shoes or work boots* • Aluminum foil
• Rain gear* • Plastic storage containers
• Signal flare
• Blankets or sleeping bags* • Paper, pencil
• Hat and gloves • Needles, thread
• Thermal underwear • Medicine dropper
• Sunglasses • Shut-off wrench, to turn off household gas and water
• Whistle
SPECIAL ITEMS Remember family members with special requirements, • Plastic sheeting
such as infants and elderly or disabled persons • Map of the area (for locating shelters)
Sanitation
For Baby*
• Formula • Toilet paper, towelettes*
• Diapers • Soap, liquid detergent*
• Bottles
• Powdered milk
• Feminine supplies*
• Medications • Personal hygiene items*
• Plastic garbage bags, ties (for personal sanitation uses)
For Adults*
• Heart and high blood pressure medication
• Insulin
• Prescription drugs
• Denture needs
• Contact lenses and supplies
• Extra eye glasses
Entertainment (based on the ages of family members)
• Games (cards) and books

Important Family Documents

• Keep these records in a waterproof, portable container:
• o Will, insurance policies, contracts deeds, stocks and bonds
• o Passports, social security cards, immunization records
• o Bank account numbers
• o Credit card account numbers and companies
• Inventory of valuable household goods, important telephone numbers
• Family records (birth, marriage, death certificates)
• Store your kit in a convenient place known to all family members. Keep a smaller version of the supplies kit in the trunk of your car.
• Keep items in airtight plastic bags. Change your stored water supply every six months so it stays fresh. Replace your stored food every six months. Re-
think your kit and family needs at least once a year. Replace batteries, update clothes, etc.
• Ask your physician or pharmacist about storing prescription medications

Cover Your Cough Serious respiratory illness like influenza, respiratory syncytial virus (RSV), whooping cough, and sever acute
respiratory syndrome (SARS) are spread by coughing or sneezing and unclean hands.

TO HELP STOP THE SPREAD OF GERMS:

• Covery your mouth and nose with a tissue when you cough of sneeze
• If you don’t have a tissue, cough or sneeze into your upper sleeve, not your hands
• Put your used tissue in the waste basket
• Clean your hands after coughing or sneezing !
• Wash with soap and water or Clean with alcohol-based and cleaner

Note: You may consider wearing a surgical mask to protect others.

Hand Hygiene in Emergency Situations
After an emergency, it can be difficult to find running water. However, it is still important to wash your hands to avoid illness. It is best to
wash your hands with soap and water but when water isn’t available, you can use alcohol-based products made for washing hands. Below
are some tips for washing your hands with soap and water and with alcohol-based products.

When should you wash your hands?

 Before preparing or eating food • After handling garbage
 Before and after treating a cut or wound • After handling an animal or animal waste
 Before and after tending to someone who is sick • After going to the bathroom
 After handling uncooked foods, particularly raw meat, • After changing diapers or cleaning up a child who has poultry, or fish gone to
the bathroom
 After blowing your nose, coughing, or sneezing

Techniques for Hand Hygiene with Alcohol-Based Products:

When hands are visibly dirty, they should be washed with soap and water when available. However, if soap and water are not available, use
an alcohol-based product to clean your hands. When using an alcohol-based handrub, apply product to palm of one hand and rub hands
together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on
hands varies by product.
Alcohol-based handrubs significantly reduce the number of germs on skin and are fast acting.

Proper techniques to use when washing your hands with soap and water:
1. Place your hands together under water (warm water if possible).
2. Rub your hands together for at least 15-20 seconds (with soap if possible). Wash all surfaces well, including wrists, palms, backs of
hands, fingers, and under the fingernails
3. Clean the dirt from under your fingernails.
4. Rinse the soap from your hands.
5. Dry your hands completely with a clean towel if possible (this helps remove the germs). However, if towels are not available it is okay
to air dry your hands.
6. Pat your skin rather than rubbing to avoid chapping and cracking.
7. If you use a disposable towel, throw it in the trash.
ITEMS IN MY EMERGENCY YES NO DATE REPLACED / REFRESHED
PREPAREDNESS KIT
Water
Food
First Aid Supplies
Medications & Special Items
Tools & Emergency Supplies
Sanitation Articles
Clothing & Bedding
Special Items
First Aid Kit
Pet Supplies
Emergency Car Kit

Use this checklist to help evaluate and maintain an Emergency Preparedness Kit.

IN AN EMERGENCY:
• Stay Informed!
• Know who to call / where to find help
• Know what to do if someone is hurt or sick