Emergency Preparedness Guide
for Agencies Providing Services to
Individuals with Special Needs
New York City Office of Emergency Management
April 2009
TABLE OF CONTENTS
INTRODUCTION
Purpose
Scope
Significance of Planning
How to Use this Guide
3
3
4
4
5
SECTION 1: INITIAL PLANNING AND ASSESSMENT
Identification and Assessment of Clients
Assessment of Agency Capabilities
Develop a Communications Plan
Employee Emergency Notification Plan
Client Communication Plan
6
6
9
11
11
13
SECTION 2: ONGOING ANNUAL ACTIVITIES
Education and Awareness
Maintenance: Review and Update Plans
15
15
15
SECTION 3: GENERAL EMERGENCY PLANNING TOOLS
16
SECTION 4: ADDITIONAL RESOURCES
16
APPENDICES
Appendix 1: Client Assessment Form Template
Appendix 1A: Client Assessment Form Instructions Template
Appendix 2: Agency Capabilities Assessment
Appendix 3: Employee Emergency Contact List Template
Appendix 4: Employee Emergency Notification Plan Checklist
Appendix 5: Agency Evacuation Plan Worksheet
Appendix 6: Agency Emergency Supply Checklist
Appendix 7: Sample Vendor/Supplier List
Appendix 8: Emergency Phone Number Template
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17
24
28
30
31
33
35
36
37
2
INTRODUCTION
Purpose
Delivering information to populations with special needs is challenging, especially in a place
as large and diverse as New York City. Language, culture, demographics, geographic
location, and physical, cognitive or mental capacities can impact the way information is
transmitted, received and acted upon. For the purposes of this guide, “populations with special
needs” is defined as seniors, people with disabilities and anyone who may need extra
assistance in an emergency situation. However, many portions of this guide may be useful to
service agencies serving any population in New York City.
Because many service agencies provide a direct, trusted link to the populations they serve on
a daily basis, they can play a significant role in the transmission of information about
emergencies. A service agency may initially receive information about emergencies directly
from a government agency, an umbrella organization, or trusted media sources. Such
information may include hazardous weather forecasts, potential hazards to life and safety, and
evacuation orders. It may also include pre-season preparedness information, which can be
critical for helping clients to prepare for weather-related emergencies, such as coastal storms
(including hurricanes), extreme summer heat, and severe winter weather.
One source of emergency information directed toward agencies that serve people with special
needs is the Special Needs Advanced Warning System (AWS). The AWS is a set of tools for
reaching out to pre-identified government agencies and non-governmental organizations that
regularly provide services to seniors, people with disabilities, and people with health
vulnerabilities. OEM will provide AWS agencies with targeted special needs information
related to emergency situations or potential emergency situations in New York City such as
hazardous weather forecasts, potential hazards to life safety, potential utility or transportation
disruptions, health advisories, and evacuation orders. Agencies participating in AWS will
receive this information and then convey it to their clients and contracted provider agencies.
In addition to receiving information from a trusted service agency, clients may also elect to
sign up for Notify NYC – New York City’s pilot emergency public communication system.
Notify NYC includes different forms of direct messaging, including email, text messaging,
and telephone. Anyone can sign up for the service, including agency staff members and
individual clients. For information, see www.nyc.gov/oem.
To help agencies prepare to receive and use emergency information, this Guide includes tools
for:
 Pre-season internal agency hazard and capabilities assessments;
 Pre-season and ongoing assessment and identification of clients who may be
contacted and/or notified before, during, or after an emergency;
 Steps to ensure basic levels of client emergency preparedness; and
 Creating and maintaining agency communications plans with employees and clients.
3
Scope
This guide is not intended to be an all-inclusive continuity of operations planning guide. It is
primarily focused on preparedness for emergencies such as coastal storms (including
hurricanes), although many tools in the guide may also be useful for agencies to enhance
planning efforts around response to and recovery from other types of emergencies, such as
extreme heat, severe winter weather, power outages, major transit disruptions, and pandemic
influenza.
Additionally, this guide does not directly cover post-emergency recovery and issues related to
resettlement of clients if they have evacuated. Since clients with special needs may rely on
certain services to be in place before they can resume their daily routines, there are some
references for agencies to consider so they will be able to continue and/or rapidly restore
critical client services in the event of a significant emergency.
This guide is informational, containing suggestions to be used as an agency deems appropriate
and to the extent that the agency finds them useful. The guide is not intended to provide
definitive direction.
Significance of Planning
An emergency can disrupt the everyday functions of an agency at any time. An emergency
event could include a power outage, fire, or internal systems failure, or something more
widespread that affects all of New York City or beyond. An event such as a hurricane can
create conditions that are unsafe for all New Yorkers. Those with special needs need to pay
special attention to planning ahead, to make sure that the everyday systems they may rely
upon are in place. To minimize the damaging effects to clients, staff and property, it is critical
for the agencies that serve them to have plans and protocols in place to:
 Communicate with staff, clients, board of directors, vendors and other partners;
 Promote the safety of staff, clients and volunteers;
 Maintain mission critical functions and services;
 Protect facilities, equipment, records and other data;
 Resume operations as quickly as possible.
4
How to Use this Guide
This guide provides emergency planning recommendations specific to the tasks related to
agencies’ ability to receive and use emergency information. It can be used by agencies taking
their first steps in planning and will also be useful for agencies that need to enhance and/or
update existing plans to make sure they address readiness and capabilities.
This guide is structured into three sections with the assumption that the initial planning
detailed in Section 1 will occur as soon as practicable after agencies receive the guide.
The first section of this guide, Initial Planning and Assessment, provides planning guidance to
agencies to ensure their readiness to receive and use emergency information. It includes
concrete steps for:
 Agency capability and hazard assessments;
 Client assessments; and
 Development of communications plans.
The second section, Ongoing Annual Activities, addresses ways to provide pre-season
education and awareness tools to clients and provides tips for keeping agency plans updated.
The third section, General Emergency Planning Tools, introduces additional worksheets and
checklists that may be useful to agencies in their continuity planning process.
Throughout the guide there will be references to checklists, templates and other resources that
can be used to help agencies in the creation of new plans or the review of existing ones.
Depending on the agency type, size, culture and other factors, these tools will need to be
customized to fit each individual agency’s needs and the distinct needs of the clients served.
The successful use of emergency information is critically reliant upon the basic assumption
that participating agencies have pre-identified clients with special needs and have a realistic
plan in place to relay messages to them.
5
SECTION 1: INITIAL PLANNING AND ASSESSMENT
Overview
By planning ahead, agencies will be able to initiate notification procedures to clients in
affected areas and maintain critical client services in the event of an emergency.
This section details the following actions:
 Identification and assessment of clients potentially in need of support;
 Assessment of agency capabilities to communicate messages to identified clients; and
 Creation of a communications plan.
The following tools are referenced in this section and can be found in the designated
Appendix location.
Tool
Appendix
Client Assessment Form Template
Client Assessment Form Instructions Template
1
1A
Agency Capabilities Assessment
2
Employee Emergency Contact List Template
3
Employee Emergency Notification Plan Checklist
4
Identification and Assessment of Clients
Agencies can prepare to push relevant emergency information to all their clients and engage
in active two-way communication with their most vulnerable clients by taking the following
steps:
Step 1: Outreach: Identify and/or assess clients potentially needing support
Agencies need to assess all clients to identify who may be impacted by an emergency,
including who may need to evacuate, where they will go and how they will get there. They
also need to determine who may shelter-in-place (stay where they are) and whether they have
the appropriate plans in place to do so safely. The Client Assessment Form Template
(Appendix 1) and Instructions Template (Appendix 1A) provide guidance for agencies to
determine which clients may need assistance in the event of an emergency (including a
hurricane), their location, the method by which they can receive messages, and other
considerations.
6
Agencies may use the form and instructions as they are with minor modifications. Areas that
must be developed by each agency are highlighted in both documents. Ideally, however,
agencies should adjust current information collection and assessment methods already used,
to reflect hurricane/other disaster specific information needs. Agencies should also consider
how the information will be used, stored, and accessed, and work with their legal counsel to
discuss confidentiality issues and develop any necessary release of information language.
In addition, when used in conjunction with the “Ready New York for Seniors and People with
Disabilities” guide (available at www.nyc.gov/readyny), the assessment tool is a way to assist
clients in the critical task of personal emergency preparedness. The assessment tool is
designed to be completed through a one-on-one interaction of a staff member or volunteer
with a client. This can be done through regular in-home visits for home-based care agencies,
or by working with clients who participate in neighborhood-based programs such as Senior
Centers. Instructions in Appendix 1A are designed to be used by staff/volunteers conducting
assessments that have no familiarity with this larger document.
After doing a one-time campaign to collect the necessary assessment information, it is
important for the organization to incorporate this emergency assessment into the standard
operating procedures for new clients and into the update and maintenance of information for
existing clients (at a minimum, information should be updated every 6 months).
Step 2: Organize your data
Once the information is collected in Step 1, it should be compiled into a database, or at the
very least included in client hard files. Electronic and online databases permit multiple staff
members to update the information and to access the information outside of the office, which
may be important during an emergency. Such databases may also speed the process of
identifying and sorting the client information to determine who should be contacted and in
what order or priority (factoring in the type of the emergency).
 Agencies should consider how information from the Client Assessment Form
(Appendix 1) will be used, before creating fields and entering information in a
database or organizing hard files. Here are two examples to illustrate this:
 If agencies are prioritizing call lists to contact the most vulnerable clients
first, the database must have a field that indicates the status of each client
to assist in determining his/her priority level. This may vary by the type of
emergency (e.g. the most vulnerable clients during a hurricane may not be
the same as the most vulnerable clients during extreme summer heat). Care
should be taken to not assign arbitrary values for the vulnerability status of
a client.
 The Client Assessment Form includes information on client preparedness.
Instead of adding a field for every item on the check list, agencies should
decide on a basic level of preparedness and indicate in a “preparedness”
field whether the client meets those criteria. Include only information that
will be used. Think of other fields/or paper forms that will be needed to
carry out all the actions in your Client Communication Plan.
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 Agencies should also consider using its database to capture information about
communication needs that are outlined in their Client Communications Plan and create
reports/lists to enable implementation of each section.
Step 3: Create a “Client Communication Plan”
Agencies must have a plan for how they will push out messages to clients and, ideally,
interact with their most vulnerable clients. See Client Communication Plan, page 13, below
for guidance.
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Assessment of Agency Capabilities
Once the clients have been pre-identified and their information coordinated into a list or
database, the next step is to assess agency abilities to activate and carry out the client
notifications upon receiving emergency information.
Step 1: Assess current agency capabilities under “normal circumstances”
This capabilities assessment includes an examination of the outreach capacities, processes and
resources currently in place. In other words, an internal review of whether your agency has
the human resources, client assessment information and technology in place to activate its
Client Communication Plan 24 hours a day, 7 days a week, including:
 Designated staff assigned to initiate the Client Communication Plan, and a backup if
the primary person is unavailable
 Be sure that staff have continuous 24/7 access to the email accounts or
phone lines that have been signed up to receive emergency information and
ensure that their contact information is current.
 Designated team of staff to carry out the notifications, and a backup plan if staff
cannot get to work
 Consider the use of volunteers and/or a mutual aid agreement to work with
staff from another agency (including agencies nearby and at some physical
distance).
 Ability to access the pre-identified client “list” or “database” from inside and outside
your primary office facility
 Lists and/or databases should be stored in multiple places in case the usual
facility becomes inaccessible, but remain aware of agency, legal and other
constraints around client confidentiality.
 Consider different media, e.g., hard drive, flash drive, hard copies, webbased, and be sure that the information is consistently and simultaneously
updated in all locations or formats.
 A method for making the client notifications (e.g., telephone, email, in person) and a
backup system if possible
 This will depend on both agency access to phone, email and fax, as well as
client’s access to these types of communication methods.
The “Agency Capabilities Assessment” in Appendix 2 is a checklist to be used as a guide for
participating agencies to determine their readiness level.
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Step 2: Perform an agency hazard analysis to determine risks to staff, facilities and
technology before and during a storm and other emergencies
Now that your agency has determined its current capabilities and made plans to improve them
if needed, it is important to analyze the hazards that may affect your ability to carry out
notifications to staff and clients and/or to continue critical client services (for example, if an
evacuation is ordered and your facility or staff are in an affected area).
Consider the following as you assess the vulnerability of your own agency to the hazards
associated with a coastal storm:
.
 Hurricane season is from June 1-November 30, with the greatest potential for
hurricanes in New York City from August to October.
 Determine whether any of your agency’s facilities are in a coastal storm evacuation
zone. Go to www.NYC.gov/hurricanezones and enter the address of your building
location(s). You can also call 311 (TTY: 212-504-4115) for this information.
 Even if your agency is outside an evacuation zone, you may still face hurricane-related
hazards including high winds, flooding, tornadoes, and/or loss of power or water.
These hazards can cause broken windows, damage to buildings and roofs, damage to
vehicles, loss of access to data, email and phone systems, and loss of essential utilities.
As you examine these other hazards, consider the safety of your facilities, evacuation
plans, the effect on your notification capabilities and your ability to resume operations
post-storm.
 Consider if staff live in hurricane evacuation zones, and encourage all staff to engage
in individual preparedness activities for themselves and their families. Get copies of
OEM’s “Ready New York” materials through 311 (TTY: 212-504-4115) or online at
www.NYC.gov/readyny.
 Survey your facility and make plans to protect windows, outside equipment, vehicles
and structures. Prepare to move records, computers and other items within your
facility to another location, or off of floors that may be vulnerable to flooding.
 Identify your top five critical services and assets and make plans to protect and/or
restore them.
 Work with your IT department or an outside IT consultant to identify critical systems
and back them up.
Assess the vulnerability of your agency to hazards associated with other types of emergencies:
 Make contingency staffing plans for an emergency that would greatly reduce staff
levels, such as pandemic influenza. Consider the need for telecommuting for an
extended period of time and whether your agency will be able to perform its critical
services with a high rate of staff absenteeism. See Section 3, General Emergency
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Planning Tools, for information on developing contingency plans for your agency and
staff.
Develop a Communications Plan
In the previous sections, you identified clients potentially in need of assistance and
determined agency capabilities and methods for contacting clients. Next, you should develop
a detailed “Communications Plan” if you do not already have one. This Communications Plan
should include a protocol for contacting all employees in the event of an emergency, and a
separate plan for client notifications.
Employee Emergency Notification Plan
Be prepared to provide all employees with information on when, if and how to report to work
if a coastal storm is expected, and what role, if any, they will need to play in the notification
of clients.
Step 1: Create an “Employee Emergency Contact List”
The first step in developing any communications plan is to ensure that you have up to date
contact information. Create an “Emergency Contact List” of all employees (include board
members and significant volunteers, if applicable). This list should include the employee’s
name, home telephone, office telephone and cell phone numbers, work email address and an
alternate/personal email address which can be used as a backup if your agency system goes
down.
An “Employee Emergency Contact Template” that may be useful for collection of this
information is in Appendix 3.
Step 2: Establish a method to keep list updated
Once you have collected all of this information, it must be kept current. Assign a staff
member as the point of contact for employees to proactively send their updated information,
and ask this person to update the list at agreed-upon intervals, e.g., every 3 months, and redistribute updated copies to all employees.
Step 3: Create an employee “Phone Tree”
Now that you have gathered contact information, it is important that employees know how to
contact one another and receive information during an emergency. If information about an
emergency is received, communication with employees will be vital. Phone trees are an
effective method of disseminating critical information among multiple employees by having
everyone share in the process. In cases where time is of the essence, a phone tree will
distribute the responsibility for emergency notification among all staff to ensure all
individuals receive timely notification of the emergency without overburdening any one
person. When designing your agency’s tree, consider the following:
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 Depending on the size of the organization, the tree can be a simple call down from one
person to another, or a more complex tree that branches off into different departments
or programs;
 Designate staff who have the authority to initiate the employee call down (identify a
backup);
 Designate staff who will have the authority to create and approve messages for the call
down;
 Define a procedure for the tree to function in the event an individual cannot be
reached, such as leaving the unreachable person a message and skipping to the next
person on the tree;
 Encourage employees to write down the message, no matter how simple, so that the
correct information moves from person to person;
 Decide whether your agency wants a “closed-face tree”, which is a way to account for
all employees receiving the message and a notification of completion of the tree to the
person in charge of initiating the tree;
 Train all employees on the use of the tree and make sure each person knows who is
calling them and who they are responsible for calling. Ensure new employees are
promptly integrated into the tree and trained.
Step 4: Determine alternate methods of communications
In addition to a phone tree, each agency should determine alternate methods of
communication, should phone lines be down or there is some other reason for a breakdown of
your phone tree. Consider the following:
 Email: The same person (and his/her backups) who will have the authority to initiate
the phone tree can also push out emergency messages to all employees via email.
 Intranet: More and more, agencies are beginning to use intranets, or internal agency
websites accessed only by employees. Consider creating a space on the homepage of
your agency’s intranet where an emergency announcement can be posted. Inform all
employees about how to log on (from office and from home if possible) to view this
information in the event of an emergency.
 Emergency phone line: Designate a phone number where employees can call to
receive pre-recorded or live emergency information. Some agencies choose to use
existing main phone numbers or hotlines for this purpose. Others may get a toll-free
number that is outside the state or jurisdiction to reduce the chances that local phone
disruptions might hinder the ability to call in for information.
 In-person communication: Consider the possibility of going to employees’ homes.
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A Checklist for creation of an “Employee Emergency Notification Plan” is located in
Appendix 4.
Client Communication Plan
The Identification and Assessment of Clients section above offers ways to assess client needs
and collect and organize relevant emergency data. Below is guidance on developing a plan for
using this data to contact clients during emergencies.
Step 1: Analyze and personalize messages
It is important to identify staff that will be triaging emergency information and making
decisions on what to do with that information (see Assessment of Agency Capabilities above).
There may be agency-specific information you want to add, such as emergency contact
information or a hotline number. Some messages, especially early on, may only be
informational and not require immediate action. State clearly what actions the client/support
person should take. It is more important to give your clients accurate information about the
emergency situation than to give them assurances. The methods and procedures your agency
already uses to communicate with clients may be utilized or may be modified as needed.
Ideally, agencies should confirm that clients:
 Received the message, and
 Understand the recommended actions to keep themselves safe.
Step 2: Determine methods of communication
There are three basic ways to communicate with clients and/or their support networks: (1) in
person, (2) by email and (3) by phone. If possible, plan on using all three methods,
considering resources and the time it takes to get the message out. For instance, you could
relay messages:
 Through blast emails to clients and their support network; and
 In-person if your staff has direct client contact.
Simultaneously, you could support this system by:
 Initiating phone contact for clients you are unable to communicate with via email
and/or in person.
The method of contact with your clients should be one with which they are familiar and
comfortable. If your clients prefer direct communication or telephone calls, consider using
these as your primary communication methods, even if initial information about the
emergency reaches your agency by email.
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If a client or support person cannot be reached, consider calling the client’s emergency
contacts.
Step 3: Create a client “Phone Tree” and prioritize calls
The Employee Emergency Notification section above has information on organizing a staff
phone tree. The same guidance can be used in creating a client phone tree, with staff being
assigned responsibility for contacting certain clients.
Agencies may want to prioritize phone notifications – contacting the most vulnerable clients
first. There is no definitive way to do this, but the Client Assessment Form (Appendix 1)
identifies some characteristics that make certain clients more vulnerable than others
(including consideration of different types of emergencies). Each agency will need to
determine their own method for prioritizing lists.
Step 4: Develop protocols/procedures for staff contacting clients
Ensure all staff that may play a role in your Client Communication Plan have access to the
information they need. Plan for equipment and electricity failures; have paper copies of
contact information.
Additionally, your plan should include phone/email scripts with specifics on what staff should
do in various situations such as:
 What happens if staff cannot make positive contact with a client?
 How should staff record interaction(s) with client and/or support network?
 How should staff handle a client in crisis?
Step 5: Prepare clients for notification and manage expectations
During the assessment process, staff should discuss with clients how their information will be
used, and what support they may or may not be able to expect during a potential emergency.
Clients should know that they and/or their support system may be contacted. It may be helpful
to create a particular name for the call down, such as “Hurricane Alerts”, so clients may better
recognize the purpose of the contacts/calls when they happen. It is best to attempt to have
staff who know the clients make the phone contacts, but preparing the clients for a call from
someone besides their primary contact will help them be less confused and anxious.
Clients can be educated on ways they can stay informed and aware of pending emergency
situations so that they are not solely dependent on your agency for information and assistance.
Ensure that staff do not promise clients that they will be contacted or that they will receive
other forms of assistance during an emergency. Clients should always be encouraged to make
their own plans, to the extent possible.
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SECTION 2: ONGOING ANNUAL ACTIVITIES
Education and Awareness
It is vital that clients are educated about the hazards associated with emergencies such as
coastal storms and given individual preparedness information to help them make emergency
plans for themselves. Ideally, some of this information will be passed on to clients during the
assessment process. Information may also be pushed out during pre-season periods. For
example, prior to or at the start of the summer, information may be given or sent concerning
preparedness for heat events and coastal storm events. There may also be periodic emergency
“test” messages or calls, which would provide additional opportunities for confirming your
agency’s readiness and for pushing preparedness information to clients.
Maintenance: Review and Update Plans
The time and resources spent establishing the plans and protocols recommended in this guide
are considerable. With all the energy that goes into creating the plans and protocols, it is
important to keep plans updated so that they will remain useful. It is recommended that
agencies update their plans every 6 months, at a minimum. Updates should incorporate:
 Lessons learned after a preparedness “test” and/or after an actual event for which
emergency information was received;
 Changes in staff contact information which affects the reliability of Phone Trees and
Client Communication Plans;
 New client information, removing former clients from contact lists.
To ensure this is done, agencies should appoint someone to be responsible for updating plans,
and have several staff put reminders in their calendars to update plans at least every 6 months.
Agencies may also want to conduct their own exercises or tests to see how long it will take to
reach all clients. If your agency does this, include a mechanism to gather feedback, evaluate,
and incorporate lessons learned.
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SECTION 3: GENERAL EMERGENCY PLANNING TOOLS
As agencies engage in assessment and planning for the receipt of emergency information, it is
also a good time to consider other components of general continuity and emergency plans that
need to be created or updated. Below is a list of some additional tools that may be used as a
foundation to implement further planning processes. They are located in the Appendices to
this plan:
Tool
Appendix
Agency Evacuation Plan Worksheet
5
Agency Emergency Supply Checklist
6
Sample Vendor/Supplier List
7
Emergency Phone Number Template
e.g., local police, fire, utilities, local hospital
8
SECTION 4: ADDITIONAL RESOURCES
There are many resources available to further assist agencies in their disaster continuity
planning as well as for individual safety and preparedness. Below are just a few of these
resources:
www.ready.gov
The U.S. Department of Homeland Security developed this website to provide tools to help
individuals and businesses prepare for and respond to all types of emergencies. This site has
guides specific to “Older Americans” and “People with Disabilities”.
www.nod.org (click on “Emergency Preparedness”)
The National Organization on Disability has several pamphlets with useful tips and resources
on how to prepare for disasters for specific types of disabilities.
http://www.nyredcross.org/getprepared
This page links to dozens of American Red Cross safety guides on individual preparedness,
and includes one entitled “Disaster Safety Guide for Seniors & People with Disabilities”.
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Appendix 1
Client Assessment Form for Hurricanes and Other Emergencies
TEMPLATE
1. Client/Household Information
Last Name: ______________________ First Name: _____________________
Address: ____________________________________ Zip Code:___________
Phone (day): ____________________ (evening):________________________
(cell):__________________
Has pet:
Yes
Has service animal:
Email: _________________________________
No
Yes
No
Client lives at the above address year-round:
Yes
No
If no, dates living at above address: _______________________________
Client speaks and understands English:
Yes
No
If no, what language does client speak: __________________________________
Special communication needs (such as ASL): _____________________________
Date of birth: __________________________
Gender: __________________
Household member who is part of the client’s emergency support network
Name: ________________________ Relationship to client: __________________
Phone (other than above) Day: __________________ Evening: ________________
Email: _____________________________ Send emergency notifications: Yes
No
2. Other Emergency/Support Network Contact Information
(Individuals that do not live in the household who will be available to assist the client)
Local Contact
Last Name: ______________________ First Name: _____________________
Phone (day): _______________ (evening):___________(cell):__________________
Email: ________________________Relationship to client:_____________________
Send emergency notifications:
Yes
No
Local Contact
Last Name: ______________________ First Name: _____________________
Phone (day): _______________ (evening):___________(cell):__________________
Email: ________________________Relationship to client: _____________________
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Send emergency notifications:
Yes
No
Long Distance Contact
Last Name: ______________________ First Name: _________________________
Phone (day): _______________ (evening):___________(cell):__________________
Email: __________________ ______Relationship to client: ____________________
Send emergency notifications:
Yes
No
3. Caregiver/Support Services Information
(Could be family member, nurse, home health aide, etc.)
Last Name: ______________________ First Name: ________________________
Agency (if applicable):________________ Email: __________________________
Phone: ________________________ (cell):_________________________
Caregiver lives with client:
Yes
No
If not live-in, state frequency of services/number times per week ______
Other agencies providing in-home services: ________________________________
____________________________________________________________________
4. Mobility Information
Client uses power wheelchair / scooter
Yes
No
Client uses non-powered wheelchair
Yes
No
Client uses geri chair
Yes
No
Yes
No
Client uses other assistive equipment (such as cane or walker)
Yes
No
Client is independently mobile (without assistive equipment)
Yes
No
Client can walk / roll short distances without need for car or other vehicle Yes
No
Client needs assistance to leave bed
Yes
No
Client cannot leave bed
Yes
No
Client needs assistance to leave home
Yes
No
Client cannot leave home
Yes
No
If client uses any type of wheelchair / scooter / geri chair,
client has the ability to transfer on their own
Comments on mobility:
_______________________________________________________
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5. Transportation Information
When available, client uses the following method(s) of transportation:
Public bus
Yes
No
Subway
Yes
No
Taxi
Yes
No
Access-A-Ride
Yes
No
ambulette service
Yes
No
Private vehicle
Yes
No
Yes
No
Other paratransit /
Ambulance /
stretcher transport
Comments on transportation:
__________________________________________________
6. General Vulnerability
Client can likely sustain for at least three days without electricity in current location
and condition, without any outside services (home health aid, meals on wheels, etc.)
Yes
No
Note: See question 9 for sample vulnerability summaries, and question 10, Disaster
Plan, to ensure minimum measures are in place.
7. Hurricane Evacuation Zone Vulnerability
Client lives in the following Hurricane Evacuation Zone (circle one):
Zone A
Zone B
Zone C
Not in a Hurricane Evacuation Zone
8. Evacuation Information
Note: Also refer to question 8, Disaster Plan, for actions to take if evacuating.
A. Staying with Friends or Family
Personal Evacuation Location (Primary)
Last Name: ______________________ First Name: ____________________
Address_______________________________________________________
Phone (day): ___________ (evening):____________(cell):_______________
Email: __________________ ______Relationship: _____________________
19

Address checked to ensure location is outside of all hurricane
evacuation zones:
Yes
No

How will evacuation location contact be notified if client needs to
evacuate?
________________________________________________________

How will client get to location?________________________________

Under what conditions CAN’T the client evacuate to this location (time
of year, etc.)? ___________________________________________
Personal Evacuation Location (Secondary)
Last Name: ______________________ First Name: ____________________
Address_______________________________________________________
Phone (day): _____________ (evening):_____________ (cell):____________
Email: _______________ ______Relationship: ________________________

Address checked to ensure location is out of all hurricane evacuation
zones:
Yes
No

How will evacuation location contact be notified if client needs to
evacuate? _______________________________________________

How will client get to location? ________________________________

Under what conditions CAN’T the client evacuate to this location (time
of year, etc.)?_____________________________________________
B. Hurricane Evacuation Centers
If client does not have family or friends to stay with, fill out this section
The Hurricane Evacuation Center closest to client: _____________________
Address & cross streets: _________________________________________
(consult www.nyc.gov/hurricanezones or call 311)
If client’s usual modes of transportation (question 5 above) are not available,
client can use the following means to reach the Evacuation Center:
______________________________________________________________
No resources for evacuation (explain)
_____________________________________
Other transportation considerations
_______________________________________
C. Hospital
It is likely that client will need the support of a hospital setting during an
emergency: Yes
No
20
9. Sample Vulnerability Summaries
These indicators collect information about the client’s health, disability, living
conditions, or other factors that may help the agency to identify clients and prioritize
its communications plan.
A. If circled, shaded boxes indicate a circumstance that could make client
particularly vulnerable during a hurricane:
Question
Vulnerability Indicator
#
1
Has support person living in household?
2
Has other support system?
Receives critical services at least 3 times a
3
week?
4
Lives in Hurricane Evacuation Zone?
5
Can sustain at home as is?
6
Has a personal evacuation location?
7
Has a method to evacuate?
No
No
Yes
Yes
Yes
No
A
No
No
No
B
Yes
Yes
Yes
C
None
B. If circled, shaded boxes indicate a circumstance that could make client
particularly vulnerable during an extreme heat event:
Question
Vulnerability Indicator
#
1
Has a working air conditioner in residence?
Is willing and able to use air conditioner during excessive
2
summer heat?
If no air conditioner, is willing and able to leave home to go
3
to an air conditioned environment (friend, family, or public
place such as a cooling center)?
Has one or more of the following health risk factors?
 Age 65 or older;
 Age 4 or younger;
 Has medical condition(s) such as heart disease, high
blood pressure, psychiatric or cognitive disorders,
Diabetes Mellitus, respiratory conditions, or obesity;
 Consumes alcohol;
4
 Takes certain medications that may increase risk for
heat-related illness (always check with prescribing
physician to determine particular risks), such as tricyclic
antidepressants, antipsychotic/neuroleptic medications,
certain tranquilizers, certain medications for
Parkinson’s, diuretics, beta blockers, calcium channel
blockers, antihistamines, or illicit drugs such as
amphetamines, cocaine or “ecstasy.”
5
Lives on top floor of the building (directly under roof)?
6
Is socially isolated?
No
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
21
10. Disaster Plan (Refer to “Ready New York” guide for additional information; basics
are included here):
Items/information for client to have when remaining at home during an emergency:
Note: Anyone living in a hurricane evacuation zone should evacuate if instructed to do
so during a hurricane event)
 List of support network/emergency contact information (either on this form or
other location)
 Plan for someone to come stay with them (if needed)
 Knowledge of where safe areas are in their building
 Up to date Health Card (or comparable information)
 Doctor’s contact information
 Insurance information
 List of medications/copies of prescriptions
 List of allergies/medical alerts
 List of special equipment/communications devices
 Flash light
 Radio
 Batteries
 Water (at least three gallons of drinking water per person in household)
 Nonperishable, ready-to-eat canned foods, and a manual can opener
 Power back-up unit for necessary equipment
 Registered with Con Ed or other utility company as a Life Sustaining
Equipment customer or for other special services (if applicable)
 Refills prescriptions as soon as possible according to insurance plan
Items to take (“Go Bag”) when evacuating home:
 List of support network/emergency contact information (either on this form or
other location)
 Up to date Health Card (or comparable information)
 Doctor’s contact information
 Insurance information
 Pharmacist information
 List of medications/copies of prescriptions
 List of allergies/ medical alerts
 List of special equipment/communications devices
 Insurance card, identification, bank card, cash
 Pet/service animal supplies
 Medications
 Medical Aids
 Eye glasses
 Oxygen
 Hearing aids
 Walker
 Special dietary foods
 Bedding
 Extra clothes
Other evacuation considerations
 Support network knows where client will be going during a Hurricane
Evacuation
 Plan to secure home
22
11. Signature/Release of Information language [AGENCY SPECIFIC — insert below
(may include content such as importance of personal preparedness)]
Check List of Staff Actions [AGENCY SPECIFIC—add or delete as needed]






Client/caregiver given preparedness brochure ____
Client/caregiver given agency emergency contact number ____
Client/caregiver given list of support network/emergency contact
information (either on this form or information exists in other location) ____
Form started <date>
_________
Form completed <date> _________
Form updated <date> _________
_________
_________
_________
__________
23
Appendix 1A
Client Assessment Form for Hurricanes and Other Emergencies
INSTRUCTIONS TEMPLATE
A.
OVERVIEW / PURPOSE
Hurricanes create conditions that are unsafe for millions of New Yorkers. People with
special needs are often the most critically affected. Conditions associated with
hurricanes include storm surge, high winds, and heavy rains. As a result, there may
be utilities and transportation disruptions rendering day-to-day support systems, and
even emergency systems, unavailable.
Completing this form will help agencies identify:


Who needs to evacuate, where they will go, and how they will get there
If the client is not evacuating, what basics they should have in place
Important points to consider:




B.
Although the Client Assessment Form focuses on preparedness for specific
types of emergencies (such as hurricanes and extreme heat), the information
gathered and actions taken will be useful for any emergency.
Participation is voluntary for clients.
The preparedness elements listed in this form are the very basics. Encourage
clients to review the “Ready New York” materials (such as the guide “Ready
New York for Seniors and People with Disabilities”), and consider signing up
for Notify NYC, which is a direct emergency messaging service (information
and registration at www.nyc.gov/notifynyc).
Ensure that clients understand your agency is not the only source of
emergency information, and that they should consult other sources, including
the news, websites, and 311 (TTY: 212-504-4115). Do not provide clients with
guarantees that your agency will contact them or provide services during an
emergency. In addition to encouraging personal preparedness measures,
remind clients that they should contact 911 if they are in immediate danger,
witness a crime in progress, or have a serious injury or life-threatening
medical condition.
GENERAL GUIDANCE FOR COMPLETING FORM WITH CLIENT (TO BE
DEVELOPED BY AGENCY)




Approach
Timing/Deadlines
What to do with completed forms (copy for agency, copy for clients, etc.)
Any other agency-specific information
24
C.
COMPLETION INSTRUCTIONS
1. Client/Household Information
This section includes information on the client and (if applicable) an adult
household member who is part of their Emergency Support Network. Put N/A if
there are no other members of the household or if other members are not able to
provide support.
Next to “Send emergency notifications” indicate if client would like this person to
receive emergency notifications when a hurricane or other emergency is
threatening New York City.
2. Other Emergency/Support Network Contact Information
The people listed here should be individuals (other than the household member
who may be listed above) who the client trusts and are likely to be available when
the client needs them. Ideally the client should have an arrangement by which the
support person proactively checks on them. Ask questions like, “How often does
this person answer the phone when you call?”
It is always good to have an out-of-state contact. During wide-spread
emergencies it is often easier to call out of the area. That person in turn might be
able to call someone locally to assist the client.
Do not feel limited by the space provided on the form – gather contact information
on additional sheets for as many individuals as are available or appropriate for the
client.
3. Caregiver/Support Services Information
The client’s primary caregiver should be listed here. This may or may not be the
same as the in-home contact.
4. - 5. Mobility and Transportation Information
These sections capture information about the client’s ability to leave their home
and use available transportation with or without assistance. The information
collected will allow an agency to know if a client will independently meet his or her
needs during an emergency or will require additional assistance.
6. General Vulnerability
The purpose of this section is to identify individuals who could not function or
sustain in their homes for at least three days on their own. The particular
reason(s) could include:
 Relies on one or many support services to provide health care or critical
daily services that may not be available
 Has no support system or individual that could stay with them
 Relies on medical equipment that requires electricity
 Has medication that must be refrigerated and no alternative means of
keeping it cold
25



Has an unstable medical condition
Uses a wheelchair or has a mobility disability and lives on an upper floor
(and would therefore be stranded if elevator service was not working)
Has condition that may deteriorate when client is worried and under stress
7. Hurricane Evacuation Zone Vulnerability
You can determine which, if any, Hurricane Evacuation Zone your client lives in
by knowing their address and:


Calling 311 (TTY: 212-504-4115) or
Using the on-line Hurricane Evacuation Zone Finder at
www.nyc.gov/hurricanezones
Note: Both methods will also provide information on the closest Evacuation
Center (see question #8).
8. Evacuation Information
All clients should have a plan to evacuate somewhere if their home is unsafe or if
instructed to do so by emergency officials. For hurricanes, clients living in a
hurricane evacuation zone will need to evacuate if a hurricane is expected to hit
NYC and an evacuation has been ordered for that area. Note: Keep posted before
storm to hear which areas might need to evacuate.
A. Staying with Friends or Family
The best evacuation location is with friends or family members. Ask client
questions to help them determine whether the person listed is prepared
and able to host the client. Do they have room? Are they able to take the
client’s pet or service animal if he or she has one? Are they outside of the
hurricane evacuation zone?
B. Hurricane Evacuation Centers
As noted in section 7 above, you can identify the Evacuation Center
closest to your client by calling 311 (TTY: 212-504-4115) or visiting
www.nyc.gov/hurricanezones. You can also specify what options the client
may have for traveling to the Evacuation Center, in the event that their
usual modes of transportation are not available. For example, this may
include being picked up by a friend or relative with their own vehicle.
C. Hospital
Encourage client to discuss with a medical professional if they think they
may need a higher level of care than can be provided by caregivers,
friends, family, or shelter staff during a hurricane. Consider what they will
need to bring with them to the hospital and which hospital(s) they may go
to. Confirm that the hospitals are not in a hurricane evacuation zone.
Consider discussing health care directives with client.
9. Sample Vulnerability Summaries
This section provides a snapshot of your client’s potential vulnerability during
certain types of emergency events (the shaded boxes indicate a circumstance
26
that could make your client particularly vulnerable). The examples provided are
only suggestions – this section can be updated to include additional types of
emergencies, and to reflect vulnerabilities common to your client base. Consult
materials such as Ready New York guides, to better understand the types of
information you may want to capture.
10. Disaster Plan
Your client’s ability to protect themselves before and during an emergency, such
as evacuating before a storm hits or sustaining themselves at home during a
hurricane, is directly related to personal preparedness actions.
(AGENCY SPECIFIC) Each agency must determine what actions staff can take to
help clients prepare. At the very least, staff should document what actions client
has taken by checking the boxes. It is recommended, however, that staff work
with the client to increase their preparedness level by helping to gather
information and compile medication lists.
27
Appendix 2
Agency Capabilities Assessment
Use this form to determine whether your agency has the data, staff and methods in place to
relay messages to pre-identified clients before, during, and/or after an emergency. Questions
are divided into different sections with “yes” or “no” questions that will direct you to key elements
of the Preparedness Guide for further information.
Information Gathering and Storage (Data)
Yes
1.
Has your agency developed phone/email lists that you
would need in order to contact clients and their support
networks during emergencies?
2.
If answer to #1 above is “yes”, have you considered how
you would prioritize your phone list if necessary?
Yes
3.
If answer to #1 above is “yes”, have the lists been
updated in the last 6 months?
Yes
Is there a process in place for assessing and adding new
clients to your lists as they come to your agency for
services?
Yes
4.
No [If no, see Guide, pg. 8 and Appendix 1]
No [If no, see Guide, pg. 13 and Appendix 1]
No [If no, see Guide, pg. 8]
No [If no, see Guide, pg. 8 and Appendix 1]
Yes
5.
Is the information on these lists stored in multiple places?
6.
Is there an established plan (“Client Communication
Plan”) documenting procedures for relaying emergency
information to clients on these lists?
No [If no, consider where, other than in your
office, a hard copy and/or electronic version of
your client list can be accessed and by which
staff.]
Yes
No [If no, see Guide, pg. 13]
Human Resources (Staff)
Name:
7.
Indicate the designated point of contact at your agency to
be notified in the event that emergency information is sent
to your agency.
Title:
Email:
Office Phone:
Cell Phone:
Name:
8.
Indicate the back-up for the person designated in Question
#7.
Title:
Email:
Office Phone:
28
Cell Phone:
9.
Has your agency identified an adequate number of primary
and backup personnel who will carry out the responsibilities
under the Client Communication Plan?
Yes
No [If no, see Guide, pg. 9]
10. Are 24 hour/7 day procedures in place for activation of the
Client Communication Plan—both for personnel who will
make the notifications and their access to the phone and
email lists?
Yes
11. Does your Client Communication Plan include procedures
for tracking the number of clients reached/how you will
receive feedback from clients?
Yes
12. Does your plan include an estimate on how long it would
take to notify all clients?
Yes
13. Has your agency tested or drilled your Client
Communication Plan and Employee Phone Tree?
Yes
No [If no, see Guide, pg. 9]
No [If no, see Guide, pg. 13]
No [If no, see Guide, pg. 11]
No [If no, see Guide, pg. 15]
Technology, Facilities and Equipment (Method)
Phone calls
14.
What method of communication will you use to contact clients
on your list?
Emails
Home visits
Other
If there is a disruption in telephone or internet service, do
15. you have a plan in place to contact clients by an alternate
method?
16.
17.
If you cannot access your office, do you have a plan in
place to activate the Client Communication Plan from
another location?
Has your agency considered establishing a mutual aid
arrangement, i.e., an agreement with another agency to
share and/or borrow staff, space or other resources to
implement the Client Communication Plan if needed?
Yes
No [If no, see Guide, pg. 13]
Yes
No [If no, see Guide, pg. 9]
Yes
No [If no, see Guide, pg. 9]
Identify corrective actions for all “No” responses
Action Needed
Date Completed
29
(Please destroy all prior copies)
Last Name
Doe
First Name
Jane
To update your
information, please
contact John Roe, Title,
at
212-555-1111 or
Appendix 3
Agency Name
Employee Emergency Contact List
Template
Last updated:
______________
Office
Phone
212-5555555
Home Phone
718-5555555
Cell Phone
646-5555555
jroe@youragency.or
g
Work Email
Alternate Email
Jane@youragency.org
jdoe@hotmail.com
Hurricane
Evacuation Zone at
home, if any
Zone A, B, C or
“None”
Zip
Code
Appendix 4
Employee Emergency Notification Plan Checklist
Use this checklist and the information on pages 11 to 13 of the Guide to create your
Employee Emergency Notification Plan. Depending on your organization, you may also
want to include Board members and/or certain volunteers in your phone tree. Your
employee notification plan should be created in consideration of your agency
capabilities, as developed in Appendix 2, Agency Capabilities Assessment.
Task
1.
2.
3.
4.
5.
6.
Check box if
complete. If
incomplete,
see Guide,
pages 11-13.
Create list of all employee contact information [see Appendix 3 for a
template to collect and update this information].
Assign someone to be responsible for updating the list every 6 months
(or more frequently).
Store this information in multiple locations and in different forms, e.g.,
home and office, paper, flash drive, computer files.
Determine who will decide when to activate the Employee Emergency
Notification Plan, e.g., Executive Director, Human Resources,
Emergency Management Team leader, etc.
Determine who will create the message to be communicated and
consider creating some general/template messages ahead of time.
Develop an emergency “phone tree” to relay messages to all
employees via telephone.
□ Define procedure for continuing the phone tree if an individual
cannot be reached;
□ Determine if phone tree will be “open” or “closed” (a closed tree
includes a mechanism to notify the person who activated the
tree that all people have been accounted for).
7.
8.
9.
10.
11.
Consider the use of blast/group email to simultaneously communicate
the same message as the phone tree.
Consider additional backups such as posting emergency messages on
the agency’s intranet and designating an emergency phone line for
staff to call to get pre-recorded messages during an emergency
(including local and out-of-state lines, when possible).
Disseminate phone tree and contact list and make sure all staff
understand how it works and their individual responsibilities (including
new staff, upon their arrival).
Practice the plan with a phone tree drill twice a year (or more
frequently).
Consider using the plan for smaller emergencies throughout the year.
31
Identify corrective actions for all “incomplete” responses.
Action Needed
Date Completed
32
Appendix 5
Agency Evacuation Plan Worksheet
Some disasters will require employees to leave the workplace quickly. The ability to
evacuate staff, clients and visitors effectively can save lives. People who plan and
practice how they will get out of the building in an emergency are better prepared than
those who do not have a rehearsed exit strategy. Use this checklist to create an
evacuation plan if your agency does not have one in place, or to update the plans you
may already have.
Task
1.
2.
3.
4.
5.
Check box if
complete.
If feasible, develop a system for knowing who is in your building, including
clients and visitors, so that all can be accounted for in case there is an
emergency.
Decide in advance who has the authority to order an evacuation. Create a
chain of command so that others are authorized to act in case your
designated person is not available. If an emergency official tells you to
evacuate, do so immediately.
Identify who will shut down critical operations and lock the doors, if possible,
during an evacuation.
□ Train others who can serve as a backup if the designated person
is unavailable.
Locate and make copies of building and site maps with critical utility and
emergency routes clearly marked.
□ Identify and clearly mark entry/exit points both on the maps and
throughout the building.
□ Post maps for quick reference by employees.
□ Keep copies of building and site maps and other important
documents in your Emergency Supply Kit and also at an off-site
location.
Plan two ways out of the building from different locations throughout your
facility.
6.
Consider the feasibility of installing emergency lighting or plan to use
flashlights in case the power goes out.
7.
Establish a warning system.
□ Test systems frequently.
□ Plan to communicate with people who are hearing-impaired or have
other disabilities and those who do not speak English. (see also # 11)
8.
Designate assembly sites outside your building.
□ Pick one location near your facility and another in the general area in
case you have to move farther away.
□ Talk to your employees in advance about the importance of letting
someone know if they cannot get to the assembly site or if they must
leave it.
□ Be sure the assembly site is away from traffic lanes and is safe for
pedestrians.
33
Check box if
complete.
Task
9.
10.
11.
Try to account for all employees, clients and visitors as people arrive at the
assembly site. Take a head count.
□ Use a prepared roster or checklist if possible.
□ Ask everyone to let others know if they are leaving the assembly site.
Determine who is responsible for providing an all-clear or return-to-work
notification. Plan to cooperate with the NYPD, FDNY, first responders or
other emergency personnel responding to an emergency.
Plan for people with disabilities who may need help getting out in an
emergency.
□ Identify co-workers in your organization with special needs.
□ Engage people with disabilities in emergency planning.
□ Ask about communication difficulties, physical limitations, equipment
instructions and medication procedures.
□ Identify people willing to help co-workers and clients with disabilities
and be sure they are able to handle assisting in an emergency. This
is particularly important if someone needs to be lifted or carried.
□ Plan how you will alert people who cannot hear an alarm or
emergency instructions.
12.
13.
If your agency operates out of more than one location, establish evacuation
procedures for each individual site.
If your agency is in a high-rise building or any building with other tenants,
coordinate and practice with other tenants or businesses to avoid confusion
and potential gridlock.
14.
If you rent, lease or share space with other businesses, make sure the
building owner and other companies are committed to coordinating and
practicing evacuation procedures together.
15.
Write down, distribute and practice evacuation procedures.
16.
Train new staff on evacuation procedures.
Identify corrective actions for all “No” responses
Action Needed
Date Completed
34
Appendix 6
Agency Emergency Supply Checklist
The following items are recommended for an office “Emergency Supply Kit”. This list is
a starting point; add items that might be appropriate to your particular agency and the
needs of your employees and clients. Also consult “Ready New York” materials
(available at www.NYC.gov/readyny).
Item
Location
Bottled water (store at least one gallon/person/day for
drinking and sanitation, for at least 3 days)
Food (at least a 3-day supply of non-perishable food)
Flashlights
Battery powered AM/FM radio
Extra batteries (one set for each flashlight and the
radio)
Whistle (to signal for help)
First-Aid Kit
Wrench or pliers to turn off utilities
Manual can opener (for canned food items)
Extra sets of keys for office and agency vehicles (if
applicable)
Personal hygiene items (including moist towelettes,
soap, hand sanitizer)
Paper, pens, pencils, and other essential office
supplies
Roll of quarters (to use public payphone)
Copy of Client Notification Plan
Copy of Employee Notification Plan
Copy of Vendor/Supplier contact list
35
Appendix 7
Sample Vendor/Supplier List
Use this form to keep a list of the major suppliers and vendors you need to contact in
the event of a disaster. If possible, locate an alternate vendor now, and list their
information in case your primary vendor is affected by the disaster and cannot meet
your agency’s needs.
Vendor/Supplier 1
Contact Information
Company Name:
Contact Name:
Phone:
Material/Service Provided:
Email:
Account #:
Fax:
Alternate Vendor/Supplier 1
Company Name:
Contact Information
Contact Name:
Phone:
Material/Service Provided:
Email:
Account #:
Fax:
Vendor/Supplier 2
Contact Information
Company Name:
Contact Name:
Phone:
Material/Service Provided:
Email:
Account #:
Fax:
Alternate Vendor/Supplier 2
Company Name:
Contact Information
Contact Name:
Phone:
Material/Service Provided:
Email:
Account #:
Fax:
36
Appendix 8
Emergency Phone Number Template
Use this template to fill in emergency phone numbers applicable to your agency. Keep a
copy in your agency Emergency Supply Kit.
CONTACT
PHONE NUMBER
Emergencies
911
Non-emergency government services
311
(TTY: 212-504-4115)
Local Police Precinct
Ambulance Service
Poison Control
212-POISONS (764-7667) or
800-222-1222
(TDD: 212-689-9014)
Local Hospital(s)
Local Fire House
Con Edison
(electric/gas)
Long Island Power Authority (LIPA)
(electricity for parts of Queens)
National Grid
(gas)
American Red Cross in Greater New
York
800-752-6633
(TDD/TTY: 800-642-2308)
800-490-0025
631-755-6000
718-643-4050
877-REDCROSS
37