Free Nursing Home Emergency Preparedness Plan

Please complete this form to confirm your understanding and acknowledgment of our emergency preparedness plan.

Resident Information

Emergency Contact Information

Primary Emergency Contact

Alternate Emergency Contact

Emergency Preparedness Procedures

Please review each section and check the box to confirm your understanding and agreement:

Evacuation Plan

• I understand the designated evacuation routes and exits.

• I am aware of the assigned meeting points outside the facility in the event of an evacuation.

Shelter-in-Place Protocols

• I know the shelter-in-place locations for use during certain emergencies (e.g., severe weather).

• I understand that I must follow staff instructions during a shelter-in-place event.

Communication During an Emergency

• I am aware of the communication methods the nursing home will use to provide updates during an emergency.

• I understand that my primary and alternate emergency contacts will be notified if I am unable to respond.

Medication and Medical Equipment

• I confirm that I have provided a list of necessary medications and medical equipment to nursing home staff.

• I understand that the facility will make every effort to ensure my medications and medical needs are met during an emergency.

Special Assistance Requirements

• I have informed the nursing home of any special assistance or mobility needs I may have during an emergency.

• I understand that additional support staff will assist residents who require special assistance in an evacuation.

Plan Review and Training

• I acknowledge that I have reviewed the emergency preparedness plan and have received training on the procedures.

• I understand that drills and reviews of the emergency plan will occur periodically to ensure preparedness.

Acknowledgment and Signature

• By signing below, I confirm that I have read, understood, and agreed to comply with the Nursing Home Emergency Preparedness Plan.

Resident Signature

Name:

Date:

Assessor Signature

Name:

Date:

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