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Forms > 06 Emergency Services (51 docs)

06 Emergency Services (51 docs)

Free Forms, caregiving, nursing forms, policies, Licensing, Training, Case Management, Home Care, Assisted Living, DD, MI, HCBS

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Documents in 06 Emergency Services (51 docs) (51)

A form used to investigate accidents or exposure in community based care facilities and assisted living communities. Accident Exposure Investigation Analysis
A form used in community based care homes and various types of assisted living facilities to report accidents, incidents, and/or injury to an employee. Accident Incident Injury Report Form - Employee
This great form is used by various types of community based care facilities to report an accident, incident, and/or injury to a resident. This detailed form takes the care provider step-by-step through essential information needed when this type of occurrence takes place.  This form also contains recheck information.  

If the accident, incident or injury causes a legal action to be filed, then the information on this form could be very instrumental in showing the steps the care provider took after the event to ensure for the resident's well being. Accident Incident Injury Report Form - Resident Community Care Homes Assisted Living
A form designed to help investigate an auto accident, helpful for a risk management investigation. Useful for all types of care businesses and care facilities. Auto Accident Report
This form is designed to be part of the assisted living facility or residential care home's Emergency Fire and Disaster Plan.  It covers essential emergency contact information, and other important business information that should be used during an emergency. Business Emergency Plan Information
This form is used to report exposure to any pathogens, such as blood. Care Facility Exposure Report Form
This form is used with all new employee's, and is completed by checking off all areas that the employee has been trained in regarding safety. Care Facility Staff Safety Training Check Off List Form
An audit to make sure your facility is properly storing and handling chemicals and medication brought into the facility.

The facility should be inspected at least twice a year or quarterly to make sure these hazardous conditions/situations do not exist. Chemical Safety Storage Audit
These Earthquake Drill Cards are used to help conduct an emergency earthquake drill with staff, residents and visitors. Earthquake Drill Cards
EARTHQUAKE DRILL FORM - for evaluating earthquake drills in community care facilities, homes for the developmentally disabled and mentally ill. EARTHQUAKE DRILL FORM - for evaluating earthquake drills
This form list alert codes and signals, such as Code Red, Code Orange, Code Yellow and Code Black.  It also describes the E-Code evacuation system and rating.  This form is a good tool for managers to help them devise an emergency alert system.  This form is for use by residential care homes for the elderly, developmentally disabled, group homes for kids, secured perimeter facilities for Alzheimer's and Dementia residents, RCFE, ALF, ARF, nursing homes and assisted living facilities. ECODES EMERGENCY ALERTS & DUTIES FORM
Whenever the situation arises where a serious concern is discovered, the Administrator or Facility Manager shall gather the staff for briefing and gather the following information:


Current Situation
Pending Danger
Resident status ? resident special needs
Structural concerns
and more.... Emergency Briefing Checklist
This form is used by residential care facilities, group homes, homes for the mentally ill and developmentally disabled residential homes' staff in cases where the resident is transferred out in during an emergency situation to the hospital. Check off Emergency Transfer List Emergency Care Transfer Form for Residential Care, Assisted Living and Community Care Homes
Very simple basic Emergency Disaster Plan Form, that may be used in some states as an Emergency Disaster plan.  Full emergency plans encompass more than what can be written on this simple form.  Please see the Table of Contents for the Emergency Service Manual for additional emergency and disaster documents. Emergency Disaster Plan Form
This great fire drill evaluation form covers the essential questions and is good for assisted living businesses, small 6 bed residential care homes for the elderly, developmentally disabled and mentally ill facilities.  All types of support housing communities need to have drills to ensure everyone know what to do in an emergency and have trained.  This drill evaluation is good for fire drills, disaster drills, evacuation drills and more.  It also includes a section for staff performance. Emergency Drill Evaluation Form
This Emergency Drill Yearly Record is great for documenting down each month's emergency drills.  This form works well for assisted living businesses, small 6 bed residential care homes for the elderly, developmentally disabled and mentally ill facilities. All types of support housing communities need to have drills to ensure everyone know what to do in an emergency and have trained. This Emergency Drill Yearly Record is good for fire drills, disaster drills, evacuation drills and more. It also includes a section for recommendations. Emergency Drill Yearly Record
This Emergency Fire Equipment Quick Check List gives a good overview of an assisted living or residential care home's essential fire equipment and what should be checked or reviewed.  This form has built in reminders which enable staff to better carry out their duties. Emergency Fire Equipment Quick Check List
This form is used to list the various types of fire equipment such as fire extinguishers, Fire Alarm Companies, Emergency Lighting and so on. This form is for use by residential care homes for the elderly, developmentally disabled, group homes for kids, secured perimeter facilities for Alzheimer's and Dementia residents, nursing homes and assisted living facilities. Emergency Fire Safety Equipment & Location
This form is used to list foods and keep an inventory of foods on hand for emergencies for residential and community care facilities and board and care homes:

Below is a list of emergency foods and products you may want to have on hand in quantities large enough to feed your residents (and staff) for two weeks to a month.  Other emergency food supplies can be purchased from the local military surplus store.
Be sure to pay attention to the shelf life, replace with fresh stock before expiration, and use product on next menu. Emergency Food List Form
The facility Incident Commander will assign duties during an emergency. This form will help clearly define what the Immediate Specific Emergency Duties, Ongoing Emergency Duties, After Emergency Duties, Record Responsibilities, Shift Time Period and more. This form can be used by residential care homes for the elderly, developmentally disabled, group homes for kids, secured perimeter facilities for Alzheimer's and Dementia residents, RCFE, ALF, RCF, ARF, nursing homes and assisted living facilities. EMERGENCY JOB ASSIGNMENT
This form should be completed for each resident and lists their emergency contact information, health conditions, allergies and medications. Emergency Phone Numbers Form
Emergency Roster Supplement - this form is used in conjunction with the Resident Roster Form and the Emergency Staffing Roster Form Emergency Roster Supplement
A free form developed by ProvidersWeb to audit a facility's Emergency Services System.  Designed for use in Residential Care, Assisted Living, and Nursing Home Facilities.  By auditing your emergency service system you can help ensure things go right when an emergency does occur.

Does the facility have an emergency procedure manual in place (see Facility Care Emergency Care Policies and Procedures and Emergency Disaster Plan), and has it been updated or reviewed within the last 12 months?
Is the Emergency Phone Number Form current?
Is the Emergency Roster current (see Resident Roster)?
Is the Emergency Evacuation Routes (see Fire & Disaster Evacuation Plan ? Sample) posted in each resident?s room and elsewhere as required by state law?  (see Fire Prevention Safety Plan)
Has the Fire Drill Evaluation been conducted monthly, and reviewed for quality? ..... Emergency Service Audit
Test the staff's training and knowledge of what to do in case of an emergency using this emergency service test. Twenty-five questions.

17. If a resident has taken the wrong medication, what should you do?
18. If a resident has ingested something poisonous what should you do?
25. During the Head to Toe Survey, 15 body areas are checked, name the primary 4...: Emergency Service Test
In any emergency you need to know who you can count on.  FEMA guidelines specify getting your staff to acknowledge their acceptance of emergency duties.  This Emergency Staff Roster form serves both purposes and is good for all types of community care facilities and residential care facilities that have to comply with emergency provisions for their residents.  Good for Assisted Living Communities, Nursing Homes, Hospitals and other types of businesses too. Emergency Staffing Roster Form
Communication and suggestion form used by employee's regarding unsafe conditions and/or occupational health concerns. Employee Safety Communication and Suggestion Form
A form used by a Residential Care or Adult Assisted Living Facility to correspond with the resident's physician regarding any changes in a resident's condition. Facility to Physician Notes
This fire drill evaluation form is used by the care home staff to evaluate how they performed during a fire drill. Good for assisted living facilities, group homes and residential care homes.

Was the local fire district notified that you are going to be conducting a drill?
Was your alarm monitoring company notified of the fire drill?
Emergency Phone Number called? (fake one)
Portable telephone or cell phone taken to re-grouping area?
Was fake fire found, and residents removed from danger, first aid administered? ...... Fire Drill Evaluation
A form used by care facilities to audit and review Fire Equipment and Safety. Fire Equipment and Safety Review
This form lists general first aid and disaster supplies that should be kept on hand in case of an emergency at residential care and assisted living care facilities. 

Keep first aid supplies in containers that are easily accessible in case of emergency. ...

Note:  Remember to check expiration dates and to replenish supplies and get doctor's orders when required. First Aid Supplies for Care Facilities
This form is used by staff to assess hazardous situations and document any corrective action taken. Hazard Assessment and Correction Record
This form is used to report and document any hazardous situation. Hazard Report Form
A quiz for the staff to take dealing with hazardous chemicals to make sure they are properly trained. Hazardous Chemical Staff Quiz
This form is used to train the staff regarding hazardous chemicals that may be found in the workplace. Hazardous Chemical Training
A form used to advise others of incidents that may be unusual and warrant consideration. For community based care homes. Incident Advisory
A form used to track communication and phone calls regarding incidents that concern the care business or care facility in general. Incident Call and Communication Log - Company
A form used by a Care Facility or Care Business to track communication and phone calls regarding accidents, incidents and/or injuries that concern a resident. Incident Call and Communication Log - Resident
Form used to designate a staff member qualified to deal with all media inquiries.

We recognize the importance of the public's right to information, however within limits.   This company is a privately owned company and therefore the public does not have the right to all the information regarding company activities.   Reporters may try to coax information, stating it's the public's right to know, however, it is our duty to our residents, employees and the company to protect privacy, guard reputation, and ensure security. Media Relations Policy
A detailed information form for staff to use when a resident or client is missing.  A form to give to the police by care facility staff. Helpful document for care home staff to report a missing person.  Check list of questions to ask and information to gather in the event a resident goes missing from a care facility. Missing Person Report
This form is a check list for monthly/quarterly elopement drills.  Elopement drills are used to train staff on what to do in case a resident is missing.  It is not uncommon for residents with dementia or Alzheimer's to wander off.  Missing residents should be a considered a life threatening emergency. Monthly/Quarterly Elopement Drill - Missing Resident Drill Sample
This form is used to inventory and audit chemicals used and located at the facility and to make sure there is a Material Safety Data Sheets (MSDS) on file for each chemical kept in a binder for easy reference in case of emergency. MSDS Inventory Safety Log
Nuclear Preparedness Check off list
We all hope nuclear attack never happens, but it could and it can?t hurt to be prepared if it does.  Many people will survive.  For example if a nuclear attack occurred in Washington DC many people would die at ground zero, and it will effect the areas around Washington DC as well.  One scenario estimated that 300 thousand would die, 650 thousand would be injured, and over 700 thousand would be required to evacuate.  The world as we know it will change.   

Based on various predictions and scenarios if we are aware what could happen, then we can prepare for it.  Below is a list of things to know, things that are likely to happen and questions to answer: Nuclear Attack Check Off List
This useful form is used to conduct a quarterly safety check of a community-based care facility and grounds.  Safety of the residents, public and staff is essential for all residential care homes, assisted living facilities, and nursing homes.

The facility must always be maintained in a clean, safe, odorless and sanitary condition.  It is the Maintenance Supervisor's job to ensure this checklist is completed quarterly.  This company's desire is to always meet the state and federal laws and regulations and exceed their standard.  Other items not included on this list might become apparent, in such cases whenever a safety issue is Quarterly Safety Management Check Off
This form is used to do a roll call in the event of an emergency.  It is helpful to use during drills, and contains the essential basic resident information.  This form is for use by residential care homes for the elderly, developmentally disabled, group homes for kids, secured perimeter facilities for Alzheimers and Dementia residents, nursing homes, RCFE, ALF, ARF and assisted living facilities. Resident Roster Form
apidly, automatically generated shaking and intensity maps?combines instrumental measurements of shaking with information about local geology and earthquake location and magnitude to estimate shaking variations throughout a geographic area. The results are rapidly available via the Web through a variety of map formats, including Geographic Information System (GIS) coverages. These maps have become a valuable tool for emergency response, public information, loss estimation, earthquake planning, and post-earthquake engineering and scientific analyses. With the adoption of ShakeMap as a standard tool for a wide array of users and uses came an impressive demand for up-to-date technical documentation and more general guidelines for users and software developers. This manual is meant to address this need. ShakeMap Information
Overview of facility policy on smoking, prohibited areas and using designated smoking areas.

Smoking and using tobacco products at this facility is restricted for medical, legal and ethical reasons.  Current research clearly demonstrates that second hand smoke can be very hazardous to others. We have strict smoking guidelines.  The goal of this policy is to protect the air quality and ensure the safety of all persons who come in contact with this facility. Smoking Policy
Procedures to follow in the event of a threatening intruder in your facility. 

An intruder drill should be performed twice a year.

Per-determined code word is: ____

Call 911, if a phone is available.

Everyone is to use extreme caution.  Do not attempt to disarm.  Do not sound the fire alarm.  A fire alarm would place occupants in potential harm as they attempt to leave the building. Threatening Intruders Plan
This form is used when sending a resident to an Urgent Care Facility due to a sudden change in their condition. Urgent Care Form
US Fire Department Evacuation Plan for Small Board and Care Homes US Fire Department Evacuation Plan for Small Board and Care Homes
This form is used during an emergency for listing utility location and shut off points, at a care facility or for a care giver providing home care.

GAS/PROPANE Shut off - Shut off the gas/propane if you smell a related odor, or if you suspect a leak. Most gas shutoffs work by turning the lever 1/4 turn, if the valve won't work call 911 and the gas company. (Follow manufacture's instructions)  Cease all operations, and have everyone exit the area immediately. Once turned off, the gas/propane company must turn it back on. Utility Shut Offs In Emergencies for Care Facilities and Home Care
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