Emergency Procedures and Contact

Circles of Care must know how to contact you and know where children, who are placed with you, are at, at all times. Please see Emergency Procedure policy and Disaster and Emergency Plan policy in your handbook.

In the case of an emergency or natural disaster such as weather, hazardous spills or acts of terrorism, if care providers are going to leave town or are required to evacuate by county or city officials, they must take the children with them and provide contact and location information to Circles of Care. Furthermore, after a natural disaster, care providers must contact Circles of Care as soon as possible to provide well-being information on children in their care.

Home Information

Caregiver #1(Required)

Mobile Number(Required)

Email Address(Required)

Caregiver #2

Mobile Number

Email Address

Address(Required)

Street Address Address Line 2 City State ZIP Code

Facility #

Other Adults in the Home

Add multiple names by clicking the + button.

Protocol For Serious Illness, Injury, And Other Emergencies

Notify your Circles of Care Case Manager IMMEDIATELEY!

If anyone in the home becomes ill with a serious or highly contagious illness or is suspected of having contracted a pandemic illness including COVID-19.
If anyone residing in the home becomes seriously injured.
Of any other events which may affect a caregiver’s capacity to care for children in care.
With the contact information and duration of any emergency caregivers that are assisting with child-care during an emergency.

Continue to update Circles of Care with significant changes to the caregiver’s and children’s health as well as that of anyone who may be caring for the children.

Emergency Contacts and Caregivers

Contacts

Please designate two people who do not live with you and whom you will call to tell them of your location and contact information if the event you must evacuate your home. If you cannot be located after an emergency, Circles of Care will contact them.

Contact #1 Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Secondary Phone Number

Contact #2 Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Secondary Phone Number

Babysitters/Caregivers

Please designate two people whom you will call if needed emergency babysitting/caregiver services. Emergency babysitters/caregivers must be approved by Circles of Care before services are needed.

Contact #1 Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Secondary Phone Number

Contact #2 Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Secondary Phone Number

Circles of Care Disaster Policy

Circles of Care Caregivers are/will be required to evacuate the area with the children in their care when local or state authorities require evacuation (mandatory) due to natural emergencies, disasters related to weather, hazardous spills, acts of terrorism, or weapons of mass destruction.

Caregivers must ensure that, as part of their evacuation with the children, the following is secured and taken with them: All medications and medical supplies, placement papers and medical authorizations, Medicaid card/information, and each child’s educational portfolio.

In the event of a quarantine due to a viral or bacterial outbreak or in the event of a biological attack, Caregivers will be required to follow all quarantine guidelines issued by a government body such as the local, state, or federal government or the United States Center for Disease Control (CDC).

My Plan For Disasters That Occur Without Warning

Fires/Flash Flooding/Act of Terrorism

Plan of Action(Required)

In the event an emergency occurs without warning that prevents us from returning to my (our) home (for example fires, flash flooding or act of terrorism), we plan to (check one):

Stay with family/friends

Stay in hotel

Other

List the family/friends you plan to stay with

Names

Addresses

Phone Numbers

Alternate Plan(Required)

If not possible what is your alternate plan? Describe (provide names, addresses, and phone numbers):

Fire Safety Plan

Who will dial 911 immediately?(Required)

Fire extinguishers are located(Required)

Where are fire escape plans located?(Required)

Who will assist infants and household members who are immobile?(Required)

Who will assist those who are mentally, visually, or hearing impaired?(Required)

What is the plan to ensure medications and equipment needed will be available for children with special needs?(Required)

Special Instructions for Special Needs Children:(Required)

Hurricanes/Tornados (evacuation not mandated)

We plan to:(Required)

Evacuate

Stay in the residence

Other

Hurricanes/Tornados (evacuation mandated)

Evacuation Location (name of person or place)(Required)

Address of Evacuation Location(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number for Evacuation Location(Required)

How will you get to the evacuation location?(Required)

What is the plan to ensure medications and equipment needed will be available for children with special needs?(Required)

How will children be supervised?(Required)

Special Instructions for Special Needs Children:(Required)

Transportation Emergencies

What are your plans if foster parents are unable to transport children to necessary appointments if your vehicle is inoperable?(Required)

Special Instructions for Special Needs Children:(Required)

Basic Disaster And Emergency Preparation Information

Examples of emergency situations and disasters are numerous and can include single house fire or a hurricane that destroys cities. They can occur without warning and at any time of year, so it is important or everyone in the home to be prepared at all times.

If you must evacuate your home, make sure that you have all the necessary contact information and supplies that will be needed while you are gone. Evacuations can last less than a day or for an unknown period.

You should take, at a minimum, the following items:

At least two-week supply of medication in its container (if applicable)
Other medical supplies and equipment (such as first aid kit, glasses, face masks, gloves, etc.)
Important paperwork (such as placement and medical authorization and the educational portfolio and Medicaid cars for each child).
This form; and
Contact information for your Case Manager and the Program Director.

Even if the emergency does not require evacuation, you should make sure you have the above items readily available.

You should always have enough emergency supplies to last your family at least one week. Examples of necessary supplies are non-perishable and canned food, water, medicate, first aid supplies batteries, flashlights, diapers, and a battery-powered radio.

You should also have information on local emergency services (addresses and telephone numbers) written down in a secure place.

More information on preparing for a disaster can be located online at the Red Cross’s disaster preparedness website, www.redcross.org/prepare.

Call 2-1-1 to find out more information about shelters as well as emergency and disaster related services.

Foster homes must practice the disaster and emergency plans each year and when a child is placed in the home. The date and time of each discussion must be documented on the Evacuation Drills Form.

**During an emergency or evacuation, foster parents must contact Circles of Care daily to report on their location and safety.**

Signature of Care Provider(Required)

By entering your name, you are signing the above form and verifying that all information is correct.

Signature of Care Provider

By entering your name, you are signing the above form and verifying that all information is correct.

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