Emergency Ready Sheet

Disasters and emergencies are inevitable in today’s world. While there is a lot of information out there about how to prepare, most of it does not include the needs of people with disabilities.

Get Emergency Ready!

The Emergency Ready Sheet was created to help people with disabilities prepare for disasters and emergencies. Your Emergency Ready Sheet will have information that you would want with you at all times if a disaster or emergency strikes. Also, the questions in the Emergency Ready Sheet may make you think of things you hadn’t considered in your preparedness plans.

When you complete the form below, your Emergency Ready Sheet will be created. It will be a PDF that you can print and put in your Go Bag, and/or download to your device.

If you need help filling out this form, please call 1-800-948-1824 or email disaster@drtx.org.

"*" indicates required fields

My Information

My name * Required

First Last

My address * Required

Street Address Address Line 2 City State ZIP Code

My phone number

My email address

My Emergency Contact

Emergency contact name * Required

First Last

Emergency contact phone number * Required

Emergency contact email address

My Household

Will anyone be traveling with you?

You may or may not live with other people, like family members, roommates, or a caretaker. If you do live with other people, will they be traveling with you during an emergency?

Yes

People traveling with you * Required

List the name, age, phone number, and relationship to you for each person who will be traveling with you during an emergency. This could include your spouse, children, parents, roommates, caretaker, etc. For example: Michael Smith, 22, 555-777-8888, caretaker. Please list each person on a separate line.

My Pets

Do you have a pet?

Do you have a pet, service animal, and/or emotional support animal that will travel with you during an emergency?

Yes

Pet type(s)

What type of pet(s) will be traveling with you during an emergency? Check all that apply.

Service animal

Emotional support animal

Regular pet

Pet(s) traveling with you * Required

For each pet that will travel with you, enter its name, medications, and preferred food. Also, if a pet is a service animal or an emotional support animal, enter the tasks it performs. An example would be: Rover, heartworm and flea pills, chicken-flavored kibble, opens doors for me. Please list each pet on a separate line.

My veterinarian's name

My veterinarian's phone number

My Health or Functional Needs

My doctor's name

My doctor's phone number

My health conditions

List any disabilities or known health conditions you may be experiencing.

My medications

List your medications, including dosage and frequency, also including those only taken as-needed. Please list each medication on a separate line.

My allergies

List the things you're allergic to.

My DME or AT devices

List any Durable Medical Equipment (DME) or Assistive Technology (AT) you use. If possible, please include the serial number of the device.

My support services

For example, some people have attendant services for nursing, daily living, or mental health.

COVID-19 Vaccination

What is your COVID-19 vaccination status?

I'm fully vaccinated and boosted.

I'm fully vaccinated.

I'm partially vaccinated.

I have not received a COVID-19 vaccine.

Communication & Religion

What is the best way to communicate with you?

For example, some people communicate via American Sign Language (ASL), some people use an assistive device, some people prefer to not make eye contact, etc.

Preferred language

For example, some people prefer to speak English or Spanish, use ASL, etc.

Religious considerations

If you would like to have your religion taken into account during an emergency, please provide information about your religious preferences.

My local radio station

My Local Disaster or Emergency Contacts

These could include contacts from your county and/or your city.

Office of Emergency Management phone number

Fire Department phone number

Sheriff or Police Department phone number

Public transportation or paratransit phone number

My Utility Providers

Electric company name

Electric company phone number

Are you a critical care customer with your electric company?

Yes

I'm not sure

Gas company name

Gas company phone number

Are you a critical care customer with your gas company?

Yes

I'm not sure

Water company name

Water company phone number

Healthcare, DME & AT Providers

Healthcare agency name

Healthcare agency phone number

Emergency healthcare plan

How do you plan to access healthcare if there is an emergency?

DME provider name

What is the name of the company or agency that provides your Durable Medical Equipment (DME)?

DME provider phone number

Emergency DME plan

How do you plan to access DME if there is an emergency?

AT provider name

What is the name of the company or agency that provides your Assistive Technology (AT)?

AT provider phone number

Emergency AT plan

How do you plan to access AT if there is an emergency?

My Transportation

Emergency transportation plan

If you need to leave your home during an emergency, do you have your own transportation?

Yes, I have my own transportation

No, I don't have my own transportation

Transportation help

If you don't have your own transportation, include the name and phone number of someone who can help you with transportation during an emergency.

Name Phone number

Publication Code: DPR10

www.DRTx.org
Statewide Intake: 1-800-252-9108
Sign Language Video Phone: 1-866-362-2851
Purple 2 Video Phone: 512-271-9391
Online Intake available 24/7: intake.DRTx.org

Disclaimer: Disability Rights Texas strives to update its materials on an annual basis, and this handout is based upon the law at the time it was written. The law changes frequently and is subject to various interpretations by different courts. Future changes in the law may make some information in this handout inaccurate.

The handout is not intended to and does not replace an attorney’s advice or assistance based on your particular situation.

To request this handout in ASL, Braille, or as an audio file, contact us.

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