Nursing Home Emergency Preparedness Plan Acknowledgment Form

I, [Name], hereby acknowledge that I have received, reviewed, and understand the Emergency Preparedness Plan (EPP) for [Your Company Name]. I understand that the EPP is designed to ensure the safety and well-being of residents, staff, and visitors during emergency situations.

Training Session	Date
Introduction to Emergency Preparedness Procedures	[Month, Day, Year]
Evacuation Procedures and Routes	[Month, Day, Year]
Communication Protocols During Emergencies	[Month, Day, Year]

By signing below, I agree to adhere to the procedures outlined in the EPP and to fulfill my responsibilities as outlined in my role within the nursing home during emergency situations. I understand that failure to follow these procedures may jeopardize the safety and welfare of residents, staff, and visitors.

Emergency Contact Information

In the event of an emergency, I understand that I may contact the following individuals for assistance:

Emergency Contact Person:
Phone Number:
Email Address:

Secondary Emergency Contact Person:
Phone Number:
Email Address:

Signature

By signing below, I acknowledge that I have received and understand the Nursing Home Emergency Preparedness Plan.

[Name]

[Registered Nurse]

[Month, Day, Year]

Thank you for your attention to this matter. Should you have any questions or require further clarification regarding the Emergency Preparedness Plan, please do not hesitate to contact [Your Company Name] at [Your Company Number] or

[Name]

[Emergency Preparedness Coordinator]

[Your Email]

Please retain a copy of this acknowledgment form for your records.

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