Chippewas of Nawash - Family Pandemic Planning Guide

Social Services at Nawash has designed a Family Emergency Health Guide to help prepare families during the current wave of this pandemic.

The intention of this guide is to have every household think about their individual pandemic plans. By filling out this form, you are creating a plan that can help lessen the stress and impact of the COVID 19 pandemic on your household. The answers will also assist emergency services should they be called to your home.

Please take 5-10 minutes to fill out the Family Pandemic Planning Guide through SurveyMonkey.

Please note, we have also printed off this guide and distributed it to each household across Neyaashiinigming. If you prefer - please fill out the hard copy and:

1. Drop the plan off into the drop box outside Social Services especially if you do not have phone, or internet in the home.
OR
2. Post on your home fridge so if emergency services are called they can easily refer to this plan.

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If you need assistance or have difficulty with filling out this planning guide please contact:

Amy Ingram 519-534-3753 or clientsupport@nawashfn.ca

Question Title

* 1. Your Contact Information:

Name (First & Last Name)

Address

Email Address

Phone Number (Home or Cell)

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* 2. Is there more than one adult in the home providing care for children/adults in need of support?
(Going forward we will refer to adults as caregivers.)

Yes

Other (please specify)

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* 3. Please list all the names of the caregivers living in your household.
(i.e. a mother, father, grandparent(s), guardian, other)

Name 1:

Name 2:

Name 3:

Name 4:

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* 4. How many people are in your household including yourself?
(Living under the same roof.)

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* 5. Please provide their name(s). (This is optional)

Name 1:

Name 2:

Name 3:

Name 4:

Name 5:

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* 6. What sources of communication does your household use to contact loved ones? ( check all that apply)

Home Phone (Landline)

Cell Phone

Internet (i.e. Email, Social Media)

Other (please specify)

None of the above

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* 7. If you answered none of the above in question 6, how do you plan to communicate with loved ones if an emergency arises?
Please specify:

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* 8. Do you have a Family Pandemic Plan in place that involves family or caregiver support?
(i.e. If you become ill, is there a family member or caregiver able and aware that they should help you?)

Yes

Other (please specify)

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* 9. If you haven't already done so, please talk to a family member/caregiver about helping you in the event of an illness or an emergency. Provide name and number here:

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* 10. Do you have child care plans in place?
(i.e. if you become ill, hospitalized, or must leave for groceries or appointments during a lockdown, do you have support or a caregiver to care for your children?)

Yes

Not applicable

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* 11. Does your family live on a fixed income?

Yes

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* 12. What services might you need should you become ill or hospitalized? (List all you can think of.)

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* 13. In the circumstance there is an emergency or you become ill, would you like the Community Emergency Response team/designate to provide support to help with your needs?
(By checking yes, you are providing consent for the team to reach out to you.) (Please note that the Response team may not be able to help with all needs.)

Yes

Other (please specify)

Question Title

* 14. Do you and your family members practice the following infection control activities? (It's never too late to start or remind family of these practices.)

	Yes	No
Wash hands for at least 20 seconds	Wash hands for at least 20 seconds Yes	Wash hands for at least 20 seconds No
Stay at least 6 feet away from others	Stay at least 6 feet away from others Yes	Stay at least 6 feet away from others No
Wear surgical or N95 masks	Wear surgical or N95 masks Yes	Wear surgical or N95 masks No
Cover coughs and sneezes (i.e. in mask, in elbow)	Cover coughs and sneezes (i.e. in mask, in elbow) Yes	Cover coughs and sneezes (i.e. in mask, in elbow) No
Stay home from work or school if sick	Stay home from work or school if sick Yes	Stay home from work or school if sick No

Question Title

* 15. CHECKLIST
Do you have the following in your home?

	Yes	No
Electrolyte Drinks (i.e. Sports drinks, Gatorade, Coconut Water)	Electrolyte Drinks (i.e. Sports drinks, Gatorade, Coconut Water) Yes	Electrolyte Drinks (i.e. Sports drinks, Gatorade, Coconut Water) No
Fever/ Pain Reducers (i.e. Tylenol/Acetaminophen, Advil/Ibuprofen, Aspirin)	Fever/ Pain Reducers (i.e. Tylenol/Acetaminophen, Advil/Ibuprofen, Aspirin) Yes	Fever/ Pain Reducers (i.e. Tylenol/Acetaminophen, Advil/Ibuprofen, Aspirin) No
Cold/ Flu Symptom Relief (i.e. Nyquil, Robitussin DM, Buckley's)	Cold/ Flu Symptom Relief (i.e. Nyquil, Robitussin DM, Buckley's) Yes	Cold/ Flu Symptom Relief (i.e. Nyquil, Robitussin DM, Buckley's) No
Thermometer	Thermometer Yes	Thermometer No
Tissues (i.e. Kleenex)	Tissues (i.e. Kleenex) Yes	Tissues (i.e. Kleenex) No

Question Title

* 16. CHECKLIST
Things to Consider Keeping in Home for Emergency Supply Kit.
Do you have these supplies?

	Yes	No
Food	Food Yes	Food No
Hand Sanitizer	Hand Sanitizer Yes	Hand Sanitizer No
Thermometer	Thermometer Yes	Thermometer No
Flash Light	Flash Light Yes	Flash Light No
Batteries	Batteries Yes	Batteries No
Gloves	Gloves Yes	Gloves No
Water	Water Yes	Water No
Masks	Masks Yes	Masks No

Chippewas of Nawash - Family Pandemic Planning Guide

Question Title

* 1. Your Contact Information:

Question Title

* 2. Is there more than one *adult in the home providing care for children/adults in need of support? (Going forward we will refer to adults as *caregivers.)

Question Title

* 3. Please list all the names of the caregivers living in your household.(i.e. a mother, father, grandparent(s), guardian, other)

Question Title

* 4. How many people are in your household including yourself? (Living under the same roof.)

Question Title

* 5. Please provide their name(s). (This is optional)

Question Title

* 6. What sources of communication does your household use to contact loved ones? ( check all that apply)

Question Title

* 7. If you answered none of the above in question 6, how do you plan to communicate with loved ones if an emergency arises? Please specify:

Question Title

* 8. Do you have a Family Pandemic Plan in place that involves family or caregiver support?(i.e. If you become ill, is there a family member or caregiver able and aware that they should help you?)

Question Title

* 9. If you haven't already done so, please talk to a family member/caregiver about helping you in the event of an illness or an emergency. Provide name and number here:

Question Title

* 10. Do you have child care plans in place?(i.e. if you become ill, hospitalized, or must leave for groceries or appointments during a lockdown, do you have support or a caregiver to care for your children?)

Question Title

* 11. Does your family live on a fixed income?

Question Title

* 12. What services might you need should you become ill or hospitalized? (List all you can think of.)

Question Title

Question Title

* 14. Do you and your family members practice the following infection control activities? (It's never too late to start or remind family of these practices.)

Question Title

* 15. CHECKLIST Do you have the following in your home?

Question Title

* 16. CHECKLISTThings to Consider Keeping in Home for Emergency Supply Kit. Do you have these supplies?

Question Title

* 17. Notes:

* 2. Is there more than one adult in the home providing care for children/adults in need of support?
(Going forward we will refer to adults as caregivers.)

* 3. Please list all the names of the caregivers living in your household.
(i.e. a mother, father, grandparent(s), guardian, other)

* 4. How many people are in your household including yourself?
(Living under the same roof.)

* 7. If you answered none of the above in question 6, how do you plan to communicate with loved ones if an emergency arises?
Please specify:

* 8. Do you have a Family Pandemic Plan in place that involves family or caregiver support?
(i.e. If you become ill, is there a family member or caregiver able and aware that they should help you?)

* 10. Do you have child care plans in place?
(i.e. if you become ill, hospitalized, or must leave for groceries or appointments during a lockdown, do you have support or a caregiver to care for your children?)

* 15. CHECKLIST
Do you have the following in your home?

* 16. CHECKLIST
Things to Consider Keeping in Home for Emergency Supply Kit.
Do you have these supplies?