Emergency Plan Manual

AHCA Form 3110-1022, Rev March 2013 Rule 59A-8.027, Florida Administrative Code http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Home_Care/HHA/index.shtml#other . Page 37 of 54 As health care worker you may be separated of your family under emergency situations….be prepared: Family Communications Plan Your family may not be together when disaster strikes, so plan how you will contact one another and review what you will do in different situations. (make copy of this information for every family member) Out of Town Contact Name: ______________________________________________________________ Email:_______________________________________________________________________________ Tel. Number 1:_________________________________________ Tel. Number 2:_________________________________________ Fill out the following information for each family member and keep it up to date. Name: _______________________________________________________________________________ Social Security Number: __________________________________ Date of Birth: ___________________________________________ Important Medical Information: ____________________________________________________________ _____________________________________________________________________________________ Name: _______________________________________________________________________________ Social Security Number: __________________________________ Date of Birth: ___________________________________________ Important Medical Information: ____________________________________________________________ _____________________________________________________________________________________ Name: _______________________________________________________________________________ Social Security Number: __________________________________ Date of Birth: ___________________________________________ Important Medical Information: ____________________________________________________________ _____________________________________________________________________________________ Name: _______________________________________________________________________________ Social Security Number: __________________________________ Date of Birth: ___________________________________________ Important Medical Information: ____________________________________________________________ _____________________________________________________________________________________ Name: _______________________________________________________________________________ Social Security Number: __________________________________ Date of Birth: ___________________________________________ Important Medical Information: ____________________________________________________________ _____________________________________________________________________________________ Where to go in an emergency. Write down where your family spends the most time: Work: ________________________________________________________________________________ School and other places you frequent: ______________________________________________________ _____________________________________________________________________________________ Daycare providers ______________________________________________________________________ Workplaces and apartment buildings should all have site-specific emergency plans _____________________________________________________________________________________ Doctors: ______________________________________________________________________________ _____________________________________________________________________________________ Pharmacy: ____________________________________________________________________________ Medical Insurance: ______________________________________________________________________ _____________________________________________________________________________________ Homeowners/Rental Insurance: ___________________________________________________________ Veterinarian: __________________________________________________________________________ Angel Home Care Services, Inc.