🚨 Emergency & Disaster Plan

Required by DSHS for all home care clients — ensures caregivers know how to respond in an emergency.

✅ Emergency Plan Submitted!

Thank you. Your Emergency & Disaster Plan has been saved. A copy will be kept in your client file.

🚨 This form is required by DSHS (WAC 388-71) for all home care clients. It ensures that caregivers, family members, and emergency responders know exactly how to help you in an emergency or disaster situation. Please complete all sections as thoroughly as possible.

📋 Section 1 — Client Information

Client Full Name *

Date of Birth

Home Address *

Phone *

Nearest Cross Street

Date of Plan *

🚨 Section 2 — Emergency Contacts

Primary Emergency Contact *

Relationship *

Primary Contact Phone *

Primary Contact Alternate Phone

Secondary Emergency Contact

Relationship

Secondary Contact Phone

Secondary Contact Email

Physician Name & Phone

Preferred Hospital

⚕️ Section 3 — Medical Alerts

⚠️ This information will be shared with emergency responders if needed. Please be as specific as possible.

Critical Medical Conditions (conditions requiring immediate attention)

Critical Medications (medications that cannot be missed in an emergency)

Known Allergies (critical)

Blood Type (if known)

Medical Equipment / Devices in Use

🏃 Section 4 — Evacuation Plan

Primary Evacuation Route *

Alternate Evacuation Route

Meeting Location After Evacuation *

Transportation Needs

Client's Ability to Evacuate *

Client can self-evacuate independently Client requires caregiver assistance to evacuate Client requires emergency services assistance to evacuate

Special Evacuation Instructions

🌪️ Section 5 — Disaster Preparedness

Emergency Supply Location

72-hour emergency supply kit is available in the home Backup medications available (3+ day supply) Emergency contact list posted in a visible location in the home Client has been informed of local emergency shelter locations Client is registered with local emergency management / special needs registry Backup power source available for medical equipment (if applicable)

Nearest Emergency Shelter

Utility Shutoff Location

Additional Emergency Notes

✍️ Section 6 — Signatures

By signing below, all parties acknowledge that this Emergency & Disaster Plan has been reviewed, discussed, and agreed upon.

Client / Legal Representative Signature *

✍️ Sign here

Printed Name *

Relationship (if not client)

Date *

Agency Staff Signature

✍️ Staff signature

Staff Printed Name

Title / Role

Date

All fields marked * are required.

DSHS WAC 388-71 Compliant. Form MHH-06. Review annually or when client condition changes.