Personal Emergency Preparation Plan

First Name *

Last Name *

Phone Number: *

Ndis No.: *

Preferred Communication Method:

Name and number of emergency contact *

Personal Support

Physical Requirements: (e.g. wheelchair, wheelie walker)

Mealtime Management: (e.g. texture-modified diet, eating aids) *

Living Supports

To what extent does the participant rely on our services to meet their daily living needs?

Health Management

To what extent would the health and safety of the participant be adversely affected if our services were to be disrupted?

What health information and essential supplies would staff need to support the participant? Include current medications (brand and generic names), where medication documentation is kept, medication equipment, special food requirements, physical health needs, exercise routine, mental health requirements and emotional support needs.

Transport

Transport Method Currently Used to Access Community:

Transport Method to Use in time of Emergency:

Evacuation

Evacuation Points for Locations:

Schedule for Practice Evacuations:

Participant Acknowledgment

I acknowledge that HappinessFirst Pty Ltd has developed this Plan with my input, and input from my support network. I agree that this is my current Personal Emergency Preparation Plan and I understand that it will be implemented to ensure my health, safety and wellbeing, in the event of an emergency or disaster.

Participants Name / Advocate

Signature

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