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EMERGENCY PREPAREDNESS TEMPLATE

Health Facilities Administration-Licensing 6/11/2015 Page 1 EMERGENCY PREPAREDNESS TEMPLATE *This TEMPLATE is designed to help facilities keep track of EMERGENCY PREPAREDNESS information. The fields can be typed in online or the form can be printed out and done by hand. To save the information, print when done filling out, then do a save as and rename document. FACILITY: LICENSE #: DATE OF ORIGINAL DOCUMENT: REVISION DATE: Authority Having Jurisdiction: APPROVAL DATE: Authority Having Jurisdiction SIGNATURE: Authority Having Jurisdiction: APPROVAL DATE: Authority Having Jurisdiction SIGNATURE: Authority Having Jurisdiction: APPROVAL DATE: Authority Having Jurisdiction SIGNATURE: Health Facilities Administration-Licensing 6/11/2015 Page 2 I.

f. Emergency food and water management g. Resident relocation for both local and regional evacuations. h. Logistics plan for access to critical materials 4. List Vendors, Facilities and Agencies that have Memorandums of Understanding. Attach a copy of the MOU’s to Appendix D: Memorandum of Understanding. V. RECOVERY AND CONTINUITY OF ...

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