Disaster Preparedness Checklist

____ Make a list of all medicines including over the counter medicines

____ Have a list of telephone numbers for emergency. Be sure at least one of them is in another area. This should include family, neighbors, physicians.

____ Have a list of medical conditions, along with a list of any medical treatments required

____ Put together a “go bag” for situations when you might have to leave home for safety. This should include a change of clothes, medicines, medical equipment and supplies, food, water, toilet paper, flashlight (with extra batteries), cash, house keys, and cell phone charger.

____ Label all medical equipment with your name

____ Have supplies necessary if forced to stay home due to a disaster (food, water, first aid kit, medications, extra medical supplies if needed)

____ Notify your utility company of priority need for utilities if special medical equipment is being utilized such as oxygen

____ Locate nearest emergency shelter

____ Have important identification and insurance information easily accessible. Make copies and keep with other lists in plastic bags

____ Make sign that reads “Evacuated” to leave on door in case of evacuation

* All lists should be in plastic bags; lists and “go bag” should be easily accessible

* If you take medicine or use a medical treatment on a daily basis, be sure you have what you need on hand to make it on your own for at least one week. You should also keep a copy of your prescriptions as well as dosage or treatment information. If it is not possible to have a week-long supply of medicines and medical supplies, keep as much as possible and talk to your pharmacist or doctor about what else you should do to prepare.

Emergency Supply Kit

Basic Supplies

Think first about the basics for survival – food, water, clean air, and any life sustaining items you require.

Water

• In a disaster, water supplies may be cut off or contaminated. Store enough water for everyone in your family to last for at least 3 days
• Store one gallon of water, per person, per day. This amount will be adequate for general drinking purposes
• Three gallons per person, per day will give you enough to cook and for limited personal hygiene. Do not forget to plan for your pets
• Children, nursing mothers, and sick people may need more water
• During warmer months, more water may be necessary
• Store water in food grade plastic containers (such as clean 2-liter soft drink bottles or heavy duty, reusable plastic water containers)
• Store in a cool, dark place
• Replace water every 6 months and label container with replacement date
• If you buy bottled water:
  • Keep water in its original container; don’t re-store a bottle once it’s been opened
  • Replace water at least once per year
  •  Label bottles with their replacement date
• Treating water after a disaster:
  • If you run out of stored drinking water, stain and treat water from your water heater or the toilet reserve tank (except if you use toilet tank cleaners); you cannot drink swimming pool or spa water, but you can use it for flushing toilets or washing
    • Strain any large particles of dirt by pouring water through a couple of layers of paper towels or clean cloth
  • Next, purify water one of two ways:
    • Boil – bring to a rolling boil and maintain for 3-5 minutes. To improve taste, pour it back and forth between two clean containers to add oxygen back
    • Disinfect – If the water is clear, add 8 drops of bleach per gallon. If it is cloudy, add 16 drops. Shake or stir, then let stand 30 minutes. A slight chlorine taste and smell is normal.

Food

• When a disaster occurs, you might not have access to food and/or electricity for days, or even weeks. Store enough food to provide for your family for at least 3 days
• Store food items that are familiar (rather than buying special emergency food). Consider any dietary restrictions you may have.
• Ideal foods are shelf-stable (no refrigeration required), low in salt, and do not require cooking (e.g. canned fruit, canned vegetables, peanut butter, jam, low sodium crackers, cookies, cereals, nuts, dried fruit, canned soup or meats, juices, and non-fat dry milk). Don’t forget Ensure if you use it.
• Label a rotation date on any food container that doesn’t already have an expiration date on the package
  • Most canned foods can be safely stored for at least 18 months
  • Dry goods (e.g. cereal, crackers, cookies, dried milk, dried fruit) must be used within 6 months
• Include baby food and formula or other diet items for infants or seniors
• Store the food in airtight, pest-resistant containers in a cool, dark place
• Include a manual can opener, food utensils, paper plates, plastic cups, and paper towels
• After a power outage, refrigerated food will stay cold longer if you keep the door closed
  • Food should generally be consumed within 4 hours
  • Food in the freezer will normally remain safe for 2 days

General Items

• Dust mask to help filter contaminated air
• Plastic sheeting and duct tape to shelter in place
• Moist towelettes, garbage bags, and plastic ties for personal sanitation
• Wrench or pliers to turn off utilities
• Local maps
• Battery-powered or hank crank radio and a NOAA Weather Radio with tone alert and extra batteries for both
• Flashlight and extra batteries
• Whistle, horn, bell, etc. to signal for help
• First aid kit
• Prescription medications you take every day. You should periodically rotate medications to account for expiration dates

Additional Items to Consider for your Emergency Supply Kit

• Glasses
• Extra batteries for oxygen, breathing devices, hearing aides, wheelchairs, radios
• Pet foot, extra water or supplies for your pet or service animal
• Copies of important documents insurance policies and bank accounts in waterproof, portable container (plastic bags)
• Cash
• Sleeping bag or warm blanket for each person
• Fire extinguisher
• Matches in waterproof container

Storing Supplies

Purchasing small amount of supplies each week is easy on the budget. Choose an appropriate and accessible place to store supplies. Many people use either a large plastic garbage can or a number of small ones.

Written Notice of Home Care Consumer Rights

As a consumer of home care and services you are entitled to receive notification of the following rights both orally and in
writing. You have the right to exercise the following rights without retribution or retaliation from agency staff:

1. Receive written information concerning the agency’s policies on advance directives, including a description of applicable state law;
2. Receive information about the care and services to be furnished, the disciplines that will furnish care, the frequency of proposed visits in advance and receive information about any changes in the care and services to be furnished;
3. Receive care and services from the agency without discrimination based upon personal, cultural or ethnic preference, disabilities or whether you have formulated an advance directive;
4. Authorize a representative to exercise your rights as a consumer of home care;
5. Be informed of the full name, licensure status, staff position and employer of all persons supplying, staffing or supervising the care and services you receive;
6. Be informed and participate in planning care and services and receive care and services from staff who are properly trained and competent to perform their duties;
7. Refuse treatment within the confines of the law and be informed of the consequences of such action;
8. Participate in experimental research only upon your voluntary written consent;
9. Have you and your property to be treated with respect and be free from neglect, financial exploitation, verbal, physical and psychological abuse including humiliation, intimidation or punishment;
10. Be free from involuntary confinement, and from physical or chemical restraints;
11. Be ensured of the confidentiality of all of your records, communications, and personal information and to be informed of the agency’s policies and procedures regarding disclosure of clinical information and records;
12. Express complaints verbally or in writing about services or care that is or is not furnished, or about the lack of respect for your person or property by anyone who is furnishing services on behalf of the agency.

If you believe your rights have been violated you may contact the agency directly:

STEP UP Physical Therapy
8033 S Race Way, Centennial, CO 80122
Contact Person: Katherine Deines, PT, DPT, NCS, owner and administrator: 303-909-6007

You may also file a complaint with the Health Facilities and Emergency Medical Services Division of the Colorado Department of Public Health and Environment via mail or telephone:

4300 Cherry Creek Drive South
Denver, CO 80246
303-692-2910 or 1-800-842-8826

I attest to verbal and written receipt of the aforementioned notice of rights:

_____________________________________________ _______________________
Consumer or Authorized Representative Signature Date
_____________________________________________ _______________________
Agency Representative Signature Date