FHN Emergency Preparedness Handbook

Transcription

1 FHN Emergeny Preparedness Handbook

2 TABLE OF CONTENTS DISASTER PREPAREDNESS Introdution....4 FHN Employee and Employee Family Support....4 The Need for Pre-Planning...4 What You Can Expet from FHN....4 EMPLOYEE GUIDELINES Staff Identifiation....5 Communiations...5 Hospital Parking....5 Assignment of Personnel....5 What To Do If You Are Working When a Disaster Ours...6 What To Do If You Are Not Working When A Disaster Ours....6 EMERGENCY CONDITIONS AND BASIC STAFF RESPONSE At FHN Memorial Hospital...7 At FHN Offsite Failities...7 PURPOSE TO ASSIST EMPLOYEES AND THEIR FAMILIES IN PREPARING FOR A DISASTER SITUATION. FHN EMPLOYEE FAMILY PRE-DISASTER PLANNING Family Emergeny Plan Emergeny Supplies Kit Emergeny Contat Information Form...17 SAFE Child Pik Up Form...19 Mediation Authorization Form...20 Emergeny Release for Treatment Form...21 Emergeny Contat Numbers...22 Additional Resoures Referenes....23

3 DISASTER PREPAREDNESS INTRODUCTION Reent events have hanged the way the nation and FHN look at disaster preparedness. All the resoures (people, failities, supplies, et.) of FHN may be needed in a disaster situation. Therefore, it is imperative that eah omponent of the organization be evaluated for its readiness and ability to ensure a safe and seure working environment. Beause we are people who spend our lives in the health are profession, we are privileged to be of servie to our ommunity every day in a very speial way. We address pain, bring healing, assist with restoration, and provide hope. We also are for people who are faing a terminal illness. We join hands with our ommunity to deal with extraordinary irumstanes and events so all may return to normaly when their lives are impated by the unexpeted. Every single employee in this organization plays a ritial part in reating a positive experiene for those we serve. In a atastrophi event, it will take all of us to help ourselves and the ommunity learn a new definition for normaly. We are onfident that we will be suessful and ontinue to provide high quality patient are. FHN EMPLOYEE AND EMPLOYEE FAMILY SUPPORT As with any health are system, our most important resoure is our staff. When a disaster ours and it ontinues to unfold, many of the staff on duty may need to stay at work or report to work at unsheduled times. During these diffiult times, it is imperative to know that our employee s individual family members are ared for and safe. Not only will this peae of mind reassure our staff members, it will also enhane the staff s ability to are for our patients by enabling them to fous on the speial patient are needs at hand. THE NEED FOR PRE-PLANNING The primary barrier in ahieving this goal is the lak of personal preparedness. When a disaster situation ours, it is a surprise and there will be minimal time available to reat. Therefore, it is very important for eah employee to take the neessary time and plan for potential family needs now. Some disaster situations may require staff to remain at the hospital for an extended period. FHN will assist staff in arranging for support servies needed (e.g. hildare, overnight stay, et). WHAT YOU CAN EXPECT FROM FHN We will make every effort to: Provide the support you need in order to perform your assigned duties. Relieve you of your duties in a reasonable amount of time. Keep you informed. This handbook provides helpful information to assist you and your family with pre-planning needs in a disaster situation. EMPLOYEE GUIDELINES STAFF IDENTIFICATION FHN piture identifiation badges must be worn by staff to enter any FHN faility during an emergeny or disaster situation. For this reason, it is important that you always take your badge with you at the end of your shift instead of leaving it in your desk or loker. In addition, it may be neessary to show your badge to polie in the event that general travel is restrited during a disaster; this will enable you to travel bak and forth to work depending on the type of emergeny. Staff entranes at the hospital or other loations may be manned by Seurity staff to verify identifiation or issue temporary badges, if neessary. Spontaneous volunteers and other non-staff members will be direted where to go for proper identifiation, skill verifiation redentialing, and assignments as needed. COMMUNICATIONS During a disaster situation, a ode 100 may be paged. Staff on duty will be notified by overhead page, pager, telephone, two-way radio, or runner. Off duty, staff will be notified by ativation of telephone or pager reall lists. In addition, the loal media will be advised and publi announements will our. If loal telephone ommuniations are disrupted, needed off-duty staff may be notified by any other methods available (messenger, seurity, polie, radio, television, et.). HOSPITAL PARKING FHN Memorial Hospital staff should plan to park in the West Employee Lot and aess the hospital through the employee entrane. If there is a need for alternate parking and aess, staff will be advised at time of notifiation. Transportation to the hospital from off-site parking will be provided if neessary. ASSIGNMENT OF PERSONNEL Personnel will be assigned in aordane with need as outlined in the FHN Mass Casualty Plan, whih inludes the Hospital Inident Command System. The Hospital Inident Command system is a proess that allows the administrative leadership to reeive and analyze information and determine immediate and ongoing resoure needs. In addition, hospital department-speifi internal disaster plans may pre-assign response and staff to speifi areas and roles (please review and be familiar with your department-speifi plans). Changes affeting inpatient shedules or servies will be at the disretion of hospital administration and will be ommuniated to the appropriate nursing units and managers. Changes in surgery or outpatient shedules will require the affeted department staff members to notify patients/families of those hanges. If you have any questions or onerns, please ontat your manager. ONE OF THE TRUE TESTS OF LEADERSHIP IS THE ABILITY TO RECOGNIZE A PROBLEM BEFORE IT BECOMES AN EMERGENCY. ARNOLD H GLASGOW 4 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 5

4 WE ARE NOT PREPARING FOR THE WORLD WE LIVE IN WE ARE PREPARING FOR THE WORLD WE FIND OURSELVES IN. MICHAEL MABEE WHAT TO DO IF YOU ARE WORKING WHEN A DISASTER OCCURS Please make every effort to plan so that you will be able to remain on the job. All staff members will be needed to get us through the initial stages of a atastrophe. This is where your Family Emergeny Plan beomes very important. Understand that you will be needed, even in a apaity outside of your normal job responsibilities. Certain employees who are not normally involved in linial operations may be ross-trained for other roles and should expet to assist in those funtions and roles. Some roles are needed immediately (suh as seurity, registration, telephone operators, and deontamination teams). Other roles will be needed later (suh as ritial inident stress management (CISM) ounseling or assisting families). WHAT TO DO IF YOU ARE NOT WORKING WHEN A DISASTER OCCURS Implement your Family Emergeny Plan. Do not all or ome into your plae of work until your regularly assigned shift. Prepare to reeive a all to ome in. Assemble items you might need for the short term, suh as: Personal mediations Money Sleeping items (linens, pillow, sleeping bag, et.) Towels/soap Three days of lothing Flashlight Snaks Water Cell phone When you are alled, you will be informed of the nature of the event and where you will be needed. Bring your FHN piture identifiation badge with you. This is a requirement in order to be admitted to your plae of work. Be prepared to park elsewhere and shuttled to the hospital. Enter your workplae via the employee entrane unless otherwise instruted and proeed to your area of assignment. FHN EMERGENCY CONDITIONS AND BASIC STAFF RESPONSE ANNOUNCEMENT AND CONDITION Code Red and Fire Chimes Code 100 External Disaster Code 100 Internal Disaster Code Orange Bomb Threat Code Blue Cardia Arrest Code Green Person Needing Assistane Code Yellow Deon Evauation (no page) Code Gray Tornado Wath/Severe Storm Warning AT FHN MEMORIAL HOSPITAL DESCRIPTION INITIAL RESPONSE FOLLOW UP Smoke detetor ativated, fire alarm pulled or sprinkler ativated. Extinguish fire. Casualties in exess of the apaity of the E.R. An inident inside the faility has resulted in a safety risk to the faility struture or life safety of patients, staff and visitors. Notifiation that a bomb may be present. A Code Blue alarm has been ativated or 4 has been alled. (911 outside of hospital) Notifiaiton that someone other than a patient needs help. Patients with hazardous exposures need deontamination prior to entering the faility An area is unfit for oupany due to fire, flood, wind damage, odor, or safety of oupants. Weather Bureau reports onditions are right for tornado development or there is a severe storm warning. Ativate RACE: Resue Ativate the Alarm Contain the Fire Extinguish Fire or Evauate Building All departments ativate disaster plan unless exempt by the Administrator-on-all or Inident Command. All departments ativate disaster plan unless exempt by the Administrator-on-all or Inident Command. Obtain as muh information as possible, notify Seurity and Administration or NSO (Nursing Supervisor Offie). Start CPR. Code Blue Team responds. Call the swithboard at 4 and advise of loation. Call the swithboard at 4 and have Code paged overhead. Follow plan. Person in authority orders evauation. Evauate ambulatory patients first. Horizontal evauation is preferred. Remove objets from window sills and draw drapes if installed. Swithboard announes Code Red All Clear when advised to do so by Inident Command. Critique the event within 48 hours. Critique the event within 48 hours. Be onsious of unusual pakages. Report if found. Coordinate searh as direted. As medially indiated. Fill out appropriate inident report. Trained staff ondut Deon and debriefing. Restore patient are to highest attainable level. Determine loation and status of all personnel who were in the evauated area. Remain alert for Code Blak page. 6 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 7

5 AT FHN MEMORIAL HOSPITAL (ontinued) FHN OFFSITE FACILITIES (ontinued) ANNOUNCEMENT AND CONDITION DESCRIPTION INITIAL RESPONSE FOLLOW UP ANNOUNCEMENT AND CONDITION DESCRIPTION INITIAL RESPONSE FOLLOW UP Code Blak Tornado Warning Code Purple Infant Abdution Code Silver Person with a Weapon Code Zero Hospital Lok Down Code 25 Request for Seurity ANNOUNCEMENT AND CONDITION Code Red and/or Fire Alarm Code 100 External Disaster Code 100 Internal Disaster A tornado has been sighted in the area. Notifiation that a hild or infant has been abduted. Notifiation that a person (or persons) has a weapon in the faility. Notifiation that aess to the hospital is restrited. May be in onjuntion with other plans. Notifiation that seurity is needed at a given loation. If possible move patients to orridor. Cover patients who annot be moved. Close window shades and doors. Assign staff member to esort visitors to the afeteria. Call the Swithboard at 4 or all a "Code Purple". Have swithboard notify seurity. Provide seurity with a desription of the hild and suspeted abdutors, if known. Close all patient doors. Follow diretions of plan and initiate RUN, HIDE, FIGHT response. When safe, all the Swithboard at 4 ASAP and provide as muh information as possible. Keep visitors in patient rooms. Follow established proedures. If Seurity is needed for an emergeny, all the Swithboard at 4 and report loation and problem. AT FHN OFFSITE FACILITIES In the event of tornado damage. Reloate patients to undamaged portions of the hospital or implement the hospital-wide evauation plan. Debrief immediately following inident. Debrief as soon as possible. FHN resoures are made available to staff and visitors involved in the inident. Debrief within 48 hours following end of lokdown. Debrief within 48 hours. DESCRIPTION INITIAL RESPONSE FOLLOW UP Smoke detetor ativated, fire alarm pulled or sprinkler ativated. Follow faility speifi plan. Casualties in exess of the apaity of the E.R. Inident inside the faility has resulted in a safety risk to the faility struture or life safety of patients, staff and visitors. Ativate RACE: Resue Ativate the Alarm Contain the Fire Extinguish Fire or Evauate Building All departments ativate disaster plan unless exempt by the Administrator-on-all or Inident Command. All departments ativate disaster plan unless exempt by the Administrator-on-all or Inident Command. Complete appropriate report. Critique event within 48 hours. Critique event within 48 hours. Code Orange Bomb Threat Code Blue Cardia Arrest Code Green Person Needing Assistane Evauation (no page) Code Gray Tornado Wath/Severe Storm Warning Code Blak Tornado Warning Code Purple Infant Abdution Code Silver Person with a Weapon Faility Lok Down Request for Polie Notifiation that a bomb may be present. A Code Blue alarm has been ativated. Call 911 outside of hospital. Notifiation that someone other than a patient needs help. An area is unfit for oupany due to fire, flood, wind damage, odor, or safety of oupants. Weather Bureau reports onditions are right for tornado development or there is a severe storm warning. A tornado has been sighted in the area. Notifiation that a hild or infant has been abduted. Notifiation that a person (or persons) has a weapon in the faility. Aess to the faility is restrited. May be in onjuntion with other plans. Seurity is needed at a given loation. Obtain as muh information as possible. Call 911 and notify the Building Diretor, and Administration or NSO (Nursing Supervisor Offie). Start CPR. Code Blue Team responds, if available. Determine loation and resoures needed. Call 911, if appropriate. Person in authority orders evauation. Horizontal evauation is preferred. Remove objets from window sills and draw drapes. Diret patients and visitors to designated shelter areas in the faility. Call 911, the Hospital Nursing Supervisor or administration and Seurity. Provide 911/Seurity with a desription of the hild and suspeted abdutors, if known. Close all patient doors. Follow diretions of plan and initiate RUN, HIDE, FIGHT response. When safe, all 911 and provide as muh information as possible. Keep visitors in patient rooms. Follow established proedure. If Seurity is needed for an emergeny, all 911. Call the hospital and advise the Nursing Supervisor/ Administration and seurity of the situation. Be aware of unusual pakagesa and report, if found. Coordinate searh as direted. Evauate all patients, staff and visitors. As medially indiated. Complete appropriate inident report. Determine loation and status of all personnel who were in the evauated area. Remain alert for Code Blak page. In the event of tornado damage, reloate to undamaged portions of the faility or evauate. Debrief immediately following inident. Debrief as soon as possible. FHN resoures will be made available to staff and visitors involved in the inident. Debrief within 48 hours following end of lokdown. Debrief within 48 hours. 8 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 9

6 WE CANNOT STOP NATURAL DISASTERS BUT WE CAN ARM OURSELVES WITH KNOWLEDGE: SO MANY LIVES WOULDN T HAVE TO BE LOST IF THERE WAS ENOUGH DISASTER PREPAREDNESS. PETRA NEMCOVA FHN EMPLOYEE FAMILY PRE-DISASTER PLANNING Being prepared for emergenies is ruial at home, shool, work and in your ommunity. Disaster an strike quikly and without warning. It an fore you to evauate your neighborhood, workplae or shool or an onfine you to your home. What would you do if basi servies water, gas, eletriity or telephones were ut off? Loal offiials and relief workers will be on the sene after a disaster, but they annot reah everyone right away. The best way to make you and your family safer is to be prepared before disaster strikes. We enourage you to: Create a Family Emergeny Plan Assemble an Emergeny Supplies Kit Stay informed FAMILY EMERGENCY PLAN STEP 1: ENSURE ALL FAMILY MEMBERS ARE INVOLVED Disuss possible disasters that ould happen where you live and why you need to prepare for these events. Calmly explain the potential dangers. Plan to share responsibilities and work together as a team. Ensure all family members know their partiular responsibilities. Designate alternates, if needed. Use the Emergeny Contat Information Form on page 17 to doument emergeny ontats and information. Designate a meeting plae for your family to assemble in ase all other ommuniations are unavailable. Pratie family drills for emergeny preparedness and ondut periodi fire drills. Teah hildren who are old enough how to all 911 and give the orret information. STEP 2: PLAN FOR YOUR CHILDREN S CARE Talk to family, friends, and/or neighbors to find someone who an are for your hildren. If possible, have your hildren stay with someone with whom they are omfortable. Carry emergeny ontat numbers with you at all times and make sure your hildren s shool/aregiver has the numbers to ontat you. Obtain and understand the emergeny poliies at your hildren s shool/ dayare. Complete the SAFE Child Pik Up Form on page 19 and provide it to your hildren s shool/dayare so they know who may to pik up your hildren if you are unable to do so. Keep opies of this information so it may be used when needed by your hildren. If your hildren need to ome to the hospital disaster support employee day are enter or other loation, determine how they will get there, and what items they may need to bring with them, suh as: Presription mediations, written permission to administer, and instrutions how to administer on the Mediation Authorization Form on page 20 Written instrutions onerning any speial physial needs or allergies (Mediation Authorization Form on page 20 and Emergeny Release for Treatment Form on page 21) Speial dietary items Formula/breast milk/powdered milk in appropriate bottles Dry food suh as rakers Diapers and wipes Extra hange of lothes inluding soks and underwear Comfort item suh as a favorite toy Small games, books/magazines or hobby Family piture for younger hildren 10 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 11

7 BY FAILING TO PREPARE, YOU ARE PREPARING TO FAIL. BENJAMIN FRANKLIN STEP 3: PLAN FOR YOUR ELDERLY FAMILY MEMBERS CARE: Some of the onsiderations under Plan for Care of Children) will apply, depending on the individual. Additional items to onsider are: Heart and high blood pressure mediation Insulin and supplies Adult diapers Denture needs Contat lenses and supplies Extra eye glasses STEP 4: PLAN FOR YOUR PETS CARE Talk to family, friends, and/or neighbors to find somone to are for your pet. Many shelters, inluding the Amerian Red Cross, annot aept pets unless they are servie animals. Reommended items to aompany your pet inlude: Airline approved arrier for eah pet Pet identifiation with vaination reords Pet food and an opener, if needed Mediations and written information on any mediations Written instrutions onerning any speial physial needs or allergies. Muzzle/leash/ollar Blanket to lay on Bowls Any other small item that might help ensure omfort while you are gone. EMERGENCY SUPPLIES KIT There are nine basi ategories of items that you should have in your Kit in ase of an emergeny. The table on the following page ontains a omprehensive list. Reommended items are marked with an asterisk (*). Most items an be stored; however, ertain items, suh as presription mediations, must be added later: 1. Water 2. Food 3. First aid kit 4. Tools and supplies 5. Sanitation supplies 6. Clothing and bedding 7. Important family douments 8. Entertainment items 9. Items that are not stored Keep items in airtight plasti bags. Keep your Kit in an easy-to arry ontainer suh as a large, overed trash ontainer, a amping bakpak or a duffle bag. Store your Kit in a onvenient plae known to all family members. Keep a smaller version of the Kit in the trunk of your ar Review your Kit and family needs at least one a year. Replae batteries, update lothes, et. THERE S NO HARM IN HOPING FOR THE BEST AS LONG AS YOU RE PREPARING FOR THE WORST. STEPHEN KING 12 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 13

8 EMERGENCY SUPPLIES KIT EMERGENCY SUPPLIES KIT ITEMS 1. WATER Store at least a three-day supply of water per person (one gallon per person, per day) Notes: Two quarts are for drinking and two quarts are for food preparation/sanitation).* A normally ative person needs to drink at least two quarts of water eah day. Hot environments and intense physial ativity an double that amount. Children, nursing mothers, and ill people will need more. Store water in plasti ontainers suh as soft drink bottles. Do not use use ontainers that will deompose or break, suh as milk artons or glass bottles. Change your stored water supply every six months. 2. FOOD Store at least a three-day supply of non-perishable food Notes: Selet foods that require no refrigeration, preparation, ooking, and little or no water. Selet food items that are ompat and lightweight. Inlude a seletion of the following: Ready-to-eat anned meats, fruits, vegetables and juies Staples (salt, sugar, pepper, spies, et.) High energy foods Food for infants Comfort/stress foods If you must heat food, pak a an of Sterno (anned heat). Replae your stored food every six months. 3. FIRST AID KIT (20) adhesive bandages, various sizes (1) 5 x 9 sterile dressing (1) onforming roller gauze bandage (2) triangular bandages (2) 3 x 3 sterile gauze pads (2) 4 x 4 sterile gauze pads (1) roll 3 ohesive bandage (2) germiidal hand wipes or waterless alohol-based hand sanitizer (6) antisepti wipes Aspirin or non-aspirin pain reliever Anti-diarrhea mediation Antaid (for stomah upset) Syrup of Ipea (use to indue vomiting if advised by the Poison Control Center) Laxative Ativated haroal (use if advised by the Poison Control Center) Vitamins Note: Assemble one first aid kit for your home and one for eah ar. *Reommended items COMPLETE EMERGENCY SUPPLIES KIT ITEMS (ontinued) 4. TOOLS AND SUPPLIES Mess kits, or paper ups, plates, and plasti utensils* Battery-operated radio and extra batteries* Flashlight and extra batteries* Cash or traveler s heks, hange* Non-eletri an opener, utility knife* Fire extinguisher: small anister ABC type 14 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 15 Tube tent Pliers Tape Compass Mathes in a waterproof ontainer Aluminum foil Plasti storage ontainers Signal flare Paper, penil Needles, thread Mediine dropper Shut-off wrenh, to turn off household gas and water Whistle Plasti sheeting Map of the area (for loating shelters) A opy of this manual* 5. SANITATION Toilet paper, towelettes* Soap, liquid detergent* Feminine supplies* Personal hygiene items* Plasti garbage bags, ties (for personal sanitation uses) Plasti buket with tight lid Disinfetant Household hlorine bleah 6. CLOTHING AND BEDDING One omplete hange of lothing and footwear per person* Sturdy shoes or work boots* Rain gear* Blankets or sleeping bags* Hat and gloves Thermal underwear Sunglasses *Reommended items COMPLETE

9 EMERGENCY SUPPLIES KIT ITEMS (ontinued) 7. IMPORTANT FAMILY DOCUMENTS Soial Seurity ards Will, insurane poliies, Contrats, deeds, stoks and bonds Bank aount numbers Credit ard ompanies and aount numbers Important telephone numbers Inventory of valuable house hold goods Family reords (birth, marriage, death ertifiates) Immunization reords Note: Store opies where appropriate. 8. ENTERTAINMENT (BASED ON THE AGES OF FAMILY MEMBERS) Games, ards Books, magazines 9. ITEMS THAT ARE NOT STORED Presription mediation Cell phones and hargers Portable eletroni devies and hargers COMPLETE EMERGENCY CONTACT INFORMATION FORM Complete and share this information with members of your family, shools/day are enters, friends, neighbors. Consolidate information on wallet size ards that an be kept with you at all times. FHN employee name Home address Plae of employment Phone number SPOUSE Name Employer Work phone number Cell phone number EMERGENCY CONTACTS Name Relationship Name Relationship OUT-OF-TOWN EMERGENCY CONTACT Name Relationship 16 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 17

10 EMERGENCY CONTACT INFORMATION FORM (Continued) DESIGNATED CHILD CAREGIVER Name DESIGNATED ELDER CAREGIVER Name DESIGNATED PET CAREGIVER Name DESIGNATED MEETING LOCATION EMERGENCY SUPPLIES Loation(s) Contents Sharing resoures? What and with whom? The Emergeny Contat Information Form has been distributed to the following family members, shools, employers SAFE CHILD PICK UP FORM To be ompleted by the hild s parent(s)/guardian(s). A opy of this form should be left with the hildare provider or your hild s shool. Child s name Date of birth Male Female Shool/hildare provider Grade Usual time of pik up Days attending Mon Tue Wed Thurs Fri Parent name EMERGENCY CONTACTS In the event of an illness or emergeny, we will always attempt to ontat a parent first. In the event a parent annot be reahed, indiate who we have permission to ontat: PICK UP INFORMATION It is the responsibility of the parent to notify staff of who will be piking up their hild and if any hanges are being made. Indiate the people that are authorized to pik up your hild: Parent s signature Date 18 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 19

11 MEDICATION AUTHORIZATION FORM To be ompleted by the hild s parent(s)/guardian(s). A new form should be ompleted periodially or if any hanges our. A opy of this form should be left with the hildare provider or your hild s shool. EMERGENCY RELEASE FOR TREATMENT This form should be ompleted by parents and given to the temporary guardian for use if emergeny attention is required. (Please print) Child s name Date of birth Home phone number Emergeny phone number Shool/hildare provider Grade Teaher TO BE COMPLETED BY THE CHILD S PHYSICIAN, PHYSICIAN ASSISTANT, OR ADVANCED PRACTICE RN Physiian s printed name Offie address Offie phone number Emergeny phone number Mediation name Purpose Dosage Frequeny Time mediation is to be administered or under what irumstanes Presription date Order date Disontinuation date Diagnosis requiring mediation Expeted side effets, if any Time interval for re-evaluation Other mediations hild is reeiving Physiian s signature Date TO BE COMPLETED BY THE CHILD S PARENTS/GUARDIANS FOR PARENTS/GUARDIANS WITH A CHILD WHO NEEDS TO CARRY ASTHMA MEDICATION OR AN EPIPEN I authorize the Childare Faility/Shool Distrit and its employees and agents, to allow my hild or ward to possess and use his or her asthma mediation and/or epinephrine auto-injetor: (1) while in their are or at shool, (2) while at a hildare or shool-sponsored ativity, (3) while under the supervision of hildare or shool personnel, or (4) before or after normal hildare or shool ativities, suh as while in before-shool or after-shool are on hildare or shool-operated property. Illinois law requires the hildare servie or Shool Distrit to inform parent(s)/guardian(s) that it, and its employees and agents, inur no liability, exept for willful and wanton ondut, as a result of any injury arising from a hild s self-administration of mediation or epinephrine auto-injetor (105 ILCS 5/22-30). Parent(s)/guardian(s), if you agree, please initial We, and (father) (mother) The parents of (names of minor hildren) Give temporary guardianship of said hildren to while we are away from to or during an emergeny disaster. The named guardians have full authority to sign and approve any emergeny medial are that the above mentioned hildren may require during our absene. The hildren s primary are physiian is Phone number Known allergies inlude Present mediations inlude Should notifiation be neessary, our address is Telephone Signature of father Signature of mother Home address Date FOR ALL PARENTS/GUARDIANS By signing below, I agree that I am primarily responsible for administering mediation to my hild. However, in the event that I am unable to do or in the event of a medial emergeny, I hereby authorize the hildare faility or shool distrit and its employees and agents, in my behalf, to administer or to attempt to administer to my hild (or to allow my hild to self-administer, while under the supervision of the employees and agents of the hildare faility or shool distrit), lawfully presribed mediation in the manner desribed above. I aknowledge that it may be neessary for the administration of mediations to my hild to be performed by an individual other than a shool nurse and speifially onsent to suh praties, and I agree to indemnify and hold harmless the hildare faility or shool distrit and its employees and agents against any laims, exept a laim based on willful and wanton ondut, arising out of the administration or the hild s self-administration of mediation. Parent/guardian printed name Parent/guardian signature* Date Parent/guardian printed name Parent/guardian signature* Date *Both parents and/or guardians, if available, should sign. 20 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 21

12 EMERGENCY CONTACT NUMBERS PERSONAL EMERGENCY CONTACTS POLICE, FIRE, & AMBULANCE: 911 ILLINOIS POISON CONTROL: PHONE NUMBER ADDITIONAL RESOURCES US Department of Homeland Seurity Ready Illinois Illinois Emergeny Management Ageny Illinois Department of Publi Health Red Cross Centers for Disease Control (CDC) FEMA REFERENCES The FHN Emergeny Preparedness Handbook was derived from the Rokford Health Systems Employee Disaster Handbook. The Build a Disaster Supplies Kit was retrieved from the Amerian Red Cross website: Funded by the ASPR Grant 22 FHN Emergeny Preparedness Handbook FHN Emergeny Preparedness Handbook 23

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