Carer Back Up Plan Document

Carer Back Up Plan Document

Emergency Planning Form

If your dependant/s is in more than 6 different locations during the week or has a support plan or needs extensive supplementary information appended to their Back Up plan, then please do not use this online form but instead use the downloadable version on the website and add supplementary documentation.

Section 1: About me

Section 2: Details of the person I care for and their home

Care for more than one person? If you care for more than one person who would need to be contacted and/or looked after in an emergency please give their details below.

Section 3: Where the person I care for might be if they are not at home.

For each location please specify day of week/am/pm using the selector. (We’ve allowed space for you to record up to six places including your home. If there are more, then please use the downloadable form on the website and email it as an attachment along with an additional document detailing further places at the end of the plan)
Location 1
Location 2
Location 3
Location 4
Location 5
Location 6

Section 4: Specific information to ensure personalised care.

(Please give information that emergency, or other services, need to have to provide respectful and consistent care until your emergency contact takes over the care. If you do not have an emergency contact then details of longer term needs will be required. If the person you care for has a Support Plan or you have additional information you wish to give please please use the downloadable form on the website and email it as an attachment along with additional information.)

Please indicate whether these needs are daily and/or longer term.

Section 5: GP and medical details of the person I care for

Section 6: Other dependants in the home

(If other dependants, children and/or adults, are living in the cared for persons home please give details below. If someone should be contacted to support this dependant please give details in the Emergency Contacts section.)
Dependant 1
Dependant 2

Section 7: Emergency contacts

(Please ensure these emergency contacts know they are in this Emergency Plan.)
Emergency Contact 1
Emergency Contact 2
Emergency Contact 3

Section 8: Care at home that is paid for

(If there is support from a carer agency or other paid person please give details below and add additional contacts at the end of the plan. Please be aware they may be contacted in the event of an emergency.)
Agency 1
Agency 2

Section 9: Legal Responsibilities

e.g. Parental / Lasting Power of Attorney (LPoA)/ Deputy (Do you share parental responsibility f or anyone under the age of 18 with someone? Is there a Lasting Power of Attorney or Deputy? If so please give their details below and state ‘parental’ / LPoA / Deputy: or any other legal responsibility they have in the ‘responsibility’ section.)
First contact
Second contact

Section 10: Additional information

Section 11: Statements

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