Nursing Home Emergency Preparedness Plan Acknowledgment Form
I, [Name], hereby acknowledge that I have received, reviewed, and understand the Emergency Preparedness Plan (EPP) for [Your Company Name]. I understand that the EPP is designed to ensure the safety and well-being of residents, staff, and visitors during emergency situations.
Training Session | Date |
|---|
Introduction to Emergency Preparedness Procedures | [Month, Day, Year] |
Evacuation Procedures and Routes | [Month, Day, Year] |
Communication Protocols During Emergencies | [Month, Day, Year] |
By signing below, I agree to adhere to the procedures outlined in the EPP and to fulfill my responsibilities as outlined in my role within the nursing home during emergency situations. I understand that failure to follow these procedures may jeopardize the safety and welfare of residents, staff, and visitors.
Emergency Contact Information
In the event of an emergency, I understand that I may contact the following individuals for assistance:
Emergency Contact Person: | |
Phone Number: | |
Email Address: | |
Secondary Emergency Contact Person: | |
Phone Number: | |
Email Address: | |
Signature
By signing below, I acknowledge that I have received and understand the Nursing Home Emergency Preparedness Plan.
[Name]
[Registered Nurse]
[Month, Day, Year]
Thank you for your attention to this matter. Should you have any questions or require further clarification regarding the Emergency Preparedness Plan, please do not hesitate to contact [Your Company Name] at [Your Company Number] or
[Name]
[Emergency Preparedness Coordinator]
[Your Email]
Please retain a copy of this acknowledgment form for your records.
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