Dcc Preparedness Form – Fill Out and Use This PDF

DCC	N
(R.8/12)	COMMONWEALTH OF KENTUCKY
	Cabinet for Health and Family Services
	Department for Community Based Services
	Division of Child Care

Evacuation Planning Form for

Child Care Emergency/Disaster

Preparedness

For

Child Care Provider or Program Name:

Date:

CabinetDCC for Health and Family Services

Web(R.8/12)site: http://chfs.ky.gov/Page 1 of 12 An Equal Opportunity Employer M/F/D

Evacuation Planning Form for

Child Care Emergency/Disaster Preparedness

Table of Contents

	Page
Child Care Sample Forms for Emergency Disaster Preparedness Planning	2
Child Care Regulatory References for Emergency/Disaster Preparedness	3
Emergency/Disaster Preparedness Planning	4
Emergency/Disaster Procedures and Evacuation Plan Form	5
Child Care Roles and Responsibilities	9
Disclaimer and Signature of the Responsible Child Care Provider	11

________________________________________________________________________________________

Helpful Information Child Care Sample Forms for Emergency Disaster Preparedness Planning

In addition to this basic planning form, the following information and supportive sample forms are available at http://chfs.ky.gov/dcbs/dcc/ to assist Child Care providers in Emergency Disaster Preparedness Planning:

1.Division of Child Care Things to Know When Preparing for an Emergency and/or Disaster in Child Care

2.Sample Child Care Child Information Form

3.Sample Child Care Daily Attendance Record Form

4.Sample Child Care Emergency Disaster Preparedness Parent Information Form for Reunification

5.Sample Child Care Evacuation Response Checklist Form

6.Sample Child Care Emergency Disaster Roster Sign Out Form

7.Sample Child Care Fire Drill Form

8.Sample Child Care Earthquake and Tornado Drill Form

9.Sample Child Care Bomb Threat Information Form

10.Sample Child Care Emergency Disaster Preparedness Provider Statement

11.Child Care Emergency Disaster Preparedness Planning Checklist

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Child Care Regulatory References for Emergency/Disaster Preparedness

199.895 Evacuation plan required for child-care centers and family child-care homes -- Annual updating of plan -- Provision of plan to local emergency management officials and parents. (Effective July 12, 2012) (1) A child-care center licensed under KRS 199.896 and a family child-care home certified under KRS 199.8982 shall have a written plan for evacuation in the event of fire, natural disaster, or other threatening situation that may pose a health or safety hazard to the children in the center or home. The plan shall include but not be limited to:

A designated relocation site and evacuation route;

Procedures for notifying parents of the relocation and ensuring family reunification;

Procedures to address the needs of individual children including children with special needs;

Instructions relating to the training of staff or the reassignment of staff duties, as appropriate;

Coordination with local emergency management officials; and

A program to ensure that appropriate staff is familiar with the plan's components.

(2)A child-care center and a family child-care home shall update the evacuation plan by December 31 each year.

(3)A child-care center and a family child-care home shall retain an updated copy of the plan for evacuation, provide an updated copy to appropriate local emergency management officials, and provide a copy to each parent, custodian, or guardian of the child at the time of the child's enrollment in the program and whenever the plan is updated.

922 KAR 2:120. Child-child care center health and safety standards.

"Adequate supervision" means that qualified staff devotes full-time attention to a child in care and ensures the child is within scope of vision and range of voice.

922 KAR 2:110. Child-care center provider requirements.

The following records shall be maintained at the child-care center for five (5) years:

OA written record of quarterly, practiced earthquake and tornado drills detailing the date, time, and children who participated;

OA written record of practiced fire drills conducted monthly detailing the date, time, and children who participated;

OA written plan and diagram outlining the course of action in the event of natural or manmade disaster, posted in a prominent place.

Certification of Family Child –Care Homes/Registered Provider

922 KAR 2:100 Section 10: General Requirements, 922 KAR 2:180 Section 3: Additional Requirements

Each floor level used for child care shall have at least one (1): unblocked exit to the outside; smoke detector, fire extinguisher; and carbon monoxide detector if the home uses fuel burning appliances; or has an attached garage.

At least one (1) working land-line, unless the cabinet has been notified that the telephone is temporarily out of service) telephone on each level used for child care with a residential or commercial line and a list of emergency numbers posted by each telephone, including numbers for the police, fire station, emergency medical care and rescue squad and poison control.

A fire and tornado drill shall be conducted during hours of operation at least monthly and documented.

An earthquake drill shall be conducted during hours of operation; at least quarterly and documented.

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Emergency/Disaster Procedures and Evacuation Planning Form

General Information and Instructions

A.The first priority of a child care provider is the safety of the children and staff. Emergency/disaster plans are to provide the providers with procedures to be followed to help ensure everyone’s wellbeing.

B.When an emergency/disaster occurs, it is necessary to maintain adequate supervision of the children. In the state of Kentucky, adequate supervision is defined as qualified staff devoting full-time attention to a child in care and ensures the child is within scope of vision and range of voice.

C.Please complete the following form and respond to each question. If the question is “not applicable” to your child care setting please state so and a reason. All information with a “＊” is

required by a child care regulation.

Evacuation Planning Form for Child Care Emergency/Disaster Preparedness

Insert Provider/Program Name and Information

Name of Child Care Provider/		＊
Program
Street Address		＊
City, State, Zip Code		＊
Telephone Number		＊
Number of children enrolled		＊
Number of staff (if applicable)		＊
		Sheltering in Safe Place
The designated safe place in this		＊
location is :
	On-Site Safe Evacuate Location
The designated on-site safe location		＊
for evacuation is :
Off -Site Safe Evacuation Location #1
Name of Location		＊
Street Address		＊
City, State and Zip Code		＊
Telephone Number		＊
Directions/Evacuation route to this		＊
safe location
*Attach a map if needed
Is there a written agreement with this		Yes					No
location (Recommended as a best practice)
Off Site Safe Evacuation Location #2
Name of Location
Street Address
City, State and Zip Code
Telephone Number
Directions/Evacuation route to this
safe location
*Attach a map if needed
Is there a written agreement with this		Yes			No
location (Recommended as a best practice)
Insert Provider/Program Primary Emergency/Disaster Contact Information
Name		＊
Telephone Number		＊
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Cell Number	＊
Email Address	＊

Contact Phone Number Outside

of the Area (Recommended as a best practice)

Insert Provider/Program Emergency/Disaster Contacts (phone and /or fax, e-mail)

EMERGENCY911 or local authorities

Accounting Service

Bank
Building Inspector
Child Care Resource & Referral
Agency
http://www.kentuckypartnership.org
Community Based Services
Electric Company
FEMA
Food Service Vendor
Gas Company
Health Department
Hospitals	＊
Local Emergency Management	＊
http://kyem.ky.gov/teams/Pages/countydirectors.aspx
Inspections, License, Permits
Insurance Agent
Licensing (local/state)	＊
Newspaper
Non-emergency Fire
Non-emergency Police
Payroll Service
Poison Control	＊
Radio Stations
State Emergency Management
http://kyem.ky.gov/teams/Pages/default.aspx
Television Stations
Waste Management
Water Company

Insert Provider/Program Planning Team Members

Director

Staff Member (s)

Parent (s)

Other

Coordinating/Collaborative Agencies in the Area (phone and /or fax, e-mail)

Neighbor

Business

Church

Other

Contact Information for Coordinating Program Re-Opening (phone and /or fax, e-mail)

Facility/home Inspection/Repair

Contacting Families/Employers

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Obtaining Equipment/Supplies

Room Set up

Accessing Records

Food Service Coordination

Obtaining building inspections/licensing approval

Post Disaster Clean up Services (phone and /or fax, e-mail)

Restoration Services

Evacuation Plan

Evacuation Manager/Alternate	＊
Person responsible for “all clear”	＊
Assembly site manager/alternate	＊
Staff-person with First Aid/CPR	＊
Contact number out-of-area
(Recommended as a best practice)
E-mail address out of area
(Recommended as a best practice)
Person responsible for copy and	＊
posting of building site maps
Person responsible for marking	＊
evacuation exits
Location of evacuation exits	＊
On-site evacuation location	＊
Off-site evacuation site	＊
	Shelter-in-Place Plan
Shelter- in -Place Coordinator	＊
Shelter- in- Place Coordinator	＊
Alternate
Coordinator responsibilities	＊
Staff with First Aid/CPR	＊
Storm Shelter Locations	＊
“Seal the Room” Shelter Location(s)	＊
Staff Responsible for	＊
Maintaining/Refreshing
Emergency/Disaster Supplies
Staff Process for Maintaining Personal	＊
Supplies for Shelter-in-Place
	Communication System
How we will train our staff on	＊
emergency/disaster plans
How we will communicate our	＊
emergency/disaster plans to the
children and parents to ensure family
reunification.
In the event of a emergency/disaster,	＊
how we will communicate with the
staff/parents
	Cyber Security
How we will protect our computer
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hardware

How we will protect our computer software

If our computers are destroyed, we will use back up computers located where

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Back Up Records

Person responsible for backing up critical records including children’s/ staff records, payroll, accounts, etc.

On-site location of back up records including insurance policies, facility\home plans, bank accounts records, and computer back ups

Offsite location of additional copy of back-up records

How will the program provide for continuity if the accounting and payroll records are destroyed

Emergency/Disaster Shut Off Locations

Electricity

Water

Gas

Emergency/Disaster Equipment Locations
Alarm Box
Fire Extinguisher(s)		＊
First Aid Kit (s)		＊
CPR Face Shields		＊
Emergency/Disaster Kit
Emergency/Disaster Preparedness Plan required Communication
Please check “yes” or “no” and give the applicable date
Provided an updated copy of this plan to			＊Yes		No		Date	＊
appropriate local emergency management
officials and whenever the plan is updated.
Provided an updated copy of “The Parent			＊Yes		No
Emergency/Disaster Evacuation Information
Form for Reunification” to each parent,
custodian, or guardian of the child at the time
of the child's enrollment in the program and
whenever the plan is updated.
Emergency /Disaster Contact Information Annual Review
Date the emergency/disaster plan will be			＊
reviewed and updated

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Child Care Roles and Responsibilities

Please list each person responsible for each responsibility

Who	Primary	Alternate	Location of this
			responsibility
Declares an emergency/disaster and
actions to be taken
Calls 911
Turns off HVAC systems
Turns off Security System
Assures each child/staff has their
grab-n-go-bag
Completes room search
Contacts families
Sends family communications (e-mail)
Post sign on door
Changes voice mail
Retrieves supplies
Food/water
Attendance list
Family & staff contact information
Copies of emergency/disaster records
including emergency/disaster medical
care consent
Copies of care plan for children with
special needs
Written directions to designated
evacuation site(s)
Emergency/Disaster money
(Recommended as a best practice)
Medical supplies
Extra supplies of critical medications
Disaster supply kit
(Recommended as a best practice)
On-Going Basis	Assigned Staff	Date	Notes/Comments
Attendance records
Emergency/disaster contact lists
Emergency/disaster card and signed
emergency medical care release
Children’s grab & go bags
Rotate water and food
Rotate infant formula
Every Six Months	Assigned Staff	Date	Notes/Comments
Water: monitor expiration dates
Food: monitor expiration dates
Infant formula/food: monitor expiration
dates
First aid kit: Critical medications
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Child Care Roles and Responsibilities-continued

Every Year	Assigned Staff	Date	Notes/Comments
Emergency/Disaster Information for
each Child
Signed emergency/disaster medical
care releases
Care plans for children with special
needs
Map of area
Directions to evacuation sites
Money(This is a best practice recommendation )
Pen and paper
Whistles
Vehicle keys
Tools (hammer, crescent wrench,
screwdriver, pliers with wire cutters)
Matches in waterproof container
Plastic shielding
Every Year	Assigned Staff	Date	Notes/Comments
Duct tape
Manual can opener
Disposable bowls and utensils
Plastic bag (sealable and unsealed)
Household bleach (small bottle)
Wet towelettes
Hand sanitizer
Toilet paper
Diapers
Diaper wipes
Blankets
Check for Presence and Operation	Assigned Staff	Date	Notes/Comments
Every Six Months
Radio-battery powered
Flashlight	＊
Extra batteries (check expiration dates)	＊
Extra flash light bulbs
Charged cell phone
Cell phone

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Disclaimer

This material is presented as general plan that may be used in planning for emergencies/disasters. Successful planning for any emergency/disaster should be done by individuals, organizations and the community with the assistance of local authorities: to include planning, training and exercising (practicing) to the emergency plan. Effective emergency response calls for good judgment by all involved. The presenters of this material disclaim any and all liability, loss, damages, claims, or risks of any kind or nature sustained or incurred as a consequence or result of, whether direct or indirect, the use and/or application either directly or indirectly, or any advice, information, or methods presented herein.

Signature of the Responsible Child Care Provider

I have reviewed the procedures outlined in this Emergency/Disaster Preparedness Plan and ensure that appropriate staff is familiar with the plan's components. These procedures will be followed in case there is an emergency/disaster affecting this child care.

＊________________________________	＊_____________________________________
Signature of the Child Care Provider	Date

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