Emergency Protocol Form • Breakthrough Developmental Services, LLC

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.

1The Basics

2Medical

3Natural Hazzards

4Fire

5Emergency 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)

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