FAQ

BDS Emergency Protocol Form

Thank you for taking the time to complete this form. Some of the insurance companies/entities we work with like for us to have procedures in place in case of an emergency. We feel this helps to ensure the safety and well being of our clients and agree these procedures are necessary. To assist us, please complete the form below. We will use this information to train staff about emergencies that may take place.

1 The Basics

2 Medical

3 Natural Hazzards

4 Fire

5 Emergency Contacts

Date

Your name

First Last

Your email address (Required)

Do you have a “Go Bag”? (Required)

An emergency bag with clothing in case you need to leave the house in a hurry

If so, where is it located?

Do you have a “Emergency Kit?" (Required)

If so, where is it located?

Are there any medical conditions/diagnoses that we need to be made aware of? (Required)

Please clearly describe the medical condition(s):

Please be as detailed as possible.

Is medication required for any of the above conditions/diagnoses?

Please list the name of each medication and and the dosage

Is the patient able to self-administer the medication?

If any medication being self administered by a patient, a doctor’s prescription and instructions should be provided to BDS so that we can attach it to the Emergency Protocol to this plan. Breakthrough Developmental Services employees are not permitted to administer any medication.

Where is/are the medication(s) kept?

Are there any instances where the above listed conditions/diagnoses could become an emergency?

What are the signs of distress? What does the typical escalation process for distress look like? When should emergency services be contacted?

Name of the patient's primary medical physician: (Required)

First Last

Primary medical physician's phone number (Required)

Name of the patient's dentist? (Required)

First Last

Dentist's phone number (Required)

Where is the safest location in your home during a tornado? Typically, this is an interior room, hallway or closet without windows. (Required)

Do you have a tornado kit? (Required)

If so, where is it located?

Where is the circuit breaker for your home?

Have you practiced with the patient for what to do in case of weather related emergencies? (Required)

What is your emergency plan? (Required)

Have you toured the nearest shelter with the patient? (Required)

Where is the nearest shelter?

Is there a working smoke detector in your home? (Required)

Does your home have sprinklers? (Required)

Is there a working carbon monoxide detector in your home? (Required)

Is there an alarm in your home that summons the police and/or fire department? (Required)

Will the alarm company notify you as well? (Required)

What should we do if there is a fire while we are on premises? (Required)

Have you completed fire drills with the patient? (Required)

What are the paths to escape your home? (Required)

Where is your family meet up spot? (Required)

In case of an emergency (e.g., fire), this is the location that you want the family members to go to so that you can make sure everyone is accounted for.

In case of emergency, who should be contacted? We would like at least 2, but left room for 5. Please list the names in the order you would like them contacted.

Contact #1 (Required)

First Last

Phone (Required)

Contact #2 (Required)

First Last

Phone (Required)

Contact #3

First Last

Phone

Contact #4

First Last

Phone

Contact #5

First Last

Phone