Disaster Action Team

Date of last Tetanus shot (Within 10 years is considered up to date):
Date of last Tetanus shot (Within 10 years is considered up to date)v

Date of last Tetanus shot (Within 10 years is considered up to date)

Date of last Tetanus shot (Within 10 years is considered up to date)

Height:

Weight:

DOB:

Height:

Weight:::

Allergies (food, medication, insect, dust, latex, etc.) What happens? What do you do?

Explanations:

Huntington County Chapter

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Disaster Action Team >

What is the Disaster Action Team?

This disaster relief team provides immediate assistance to victims of disaster. We ensure the basic human needs of shelter, food, and clothing are met so that the recovery process can begin. The most common form of disaster in Huntington County is the single family house fire, but it could also include flood, tornado, chemical spill, or any type of natural or man-made disaster. The team consists of American Red Cross volunteers and it serves all of Huntington County. And when there is great need in other parts of the US our members deploy quickly to help out where needed.

What do we do?

The American Red Cross Disaster Action Team (DAT) responds to the scene of a disaster whenever requested by Police or Fire departments or the Emergency Management Agency. Our first priority is the victim(s) of disaster, to ensure their basic needs are met. The DAT members also provide canteen assistance to the emergency workers on the scene. This assistance may include giving food, hot or cold drinks, and even a recovery shelter if needed. The Red Cross is committed to taking care of the workers who serve our community!

The Red Cross is here to help you prepare for disasters

The American Red Cross is chartered by the US Congress to provide aid to those in need, and we will continue to serve that purpose in Huntington County. However by teaching disaster preparedness to our community we can help our friends and neighbors to know how to respond to emergencies. We cannot always predict when disaster may strike but we can all take steps to be prepared. This will minimize the effects of disaster and help to speed the recovery process.

*For more information about the Disaster Action Team, disaster preparedness or volunteer opportunities with the Red Cross, please call the Huntington County Chapter at (260)-356-2910 or email us at email@huntingtonredcross.org.

*If you have a disaster emergency anytime, weekdays or on weekends or holidays, please call our Disaster Services on-call phone at (800)-513-2599 ext.636.

Click Here for recent disaster pictures and information

The Red Cross Health Status Record

In order to participate in the Disaster Action Team, a Health Status Record has to be completed. You will find a copy of the Health Status Record below. You can download it, and then email it to the Huntington County Red Cross at the email above.

Health Status Record

CONFIDENTIAL

To be completed and signed by the individual. Please print all information

New

Annual Update

Change in Health Status

If this is an Annual Update, is there a change in:

Health Status

Address

Phone No.

E-mail Address

Contact Information

Name:

DSHR #

Last

First

Address:

Street

City

State

ZIP

Phone:

Home

Cell

Work

E-mail Address:

Emergency Contact:

Name

Phone

Relationship

Unit of Affiliation:

Chapter Name

Phone

Chapter Code

Group/Activity/Position:

First

Second

Third

Mark Yes if you are able and No if not able and explain any limitations under "Limitation Explanations" below (all accommodations must be requested in writing with supporting medical documentation):

yes no	Lift and carry 20 lbs multiple times per shift	yes no	Speak clearly on phone and in person
yes no	Lift and carry 50 lbs multiple times per shift	yes no	Read small print for extended periods
yes no	Stand for two-hour periods	yes no	Work for long periods on a computer
yes no	Sit for two-hour periods	yes no	Climb two or more flights of stairs
yes no	Walk on uneven terrain	yes no	Drive in daytime and at night
yes no	Walk two miles during a shift	yes no	Work/live in areas with mold/mildew
yes no	Bend or stoop multiple times during a shift	yes no	Work/live in areas with smoke/poor air
yes no	Crawl on floor or ground	yes no	Work/live with little or no privacy
yes no	Work outdoors in inclement weather	yes no	Sleep on the floor or a cot
yes no	Work in extreme heat and/or humidity	yes no	Travel by any type of transportation
yes no	Work in extreme cold	yes no	Work 12 hr shifts/nights/weekends
yes no	Able to step up/down 18 inches	yes no	Work productively during change/stress
yes no	Spend hours writing
Mark Below Yes if Required or No if Not Required
yes no	Electricity for medical devices/meds	yes no	Assistance with health monitoring
yes no	Special food or timing of meals	yes no	Air conditioning for health reasons
yes no	Access to specialized medical care

Limitation(s) Explanations:

In the last 12 months, have you been diagnosed with/continued treatment for any of the following?

yes no	Heart attack/heart disease	yes no	Bleeding disorders/anticoagulation therapy
yes no	High blood pressure	yes no	Stroke/CVA/TIA
yes no	Migraines/frequent headaches	yes no	Mental Health (Anxiety/PTSD/Bipolar)
yes no	Skin problems/breaks in skin/lesions	yes no	Seizures/nervous system/neurological
yes no	Stomach/intestine/hernia	yes no	Sleep apnea/sleep disorders
yes no	Urinary problems	yes no	Problems walking, moving
yes no	Asthma/COPD/emphysema	yes no	Back/joint/bone problems
yes no	Vision problems (Not corrected)	yes no	Immune system problems
yes no	Hearing problems/hearing aids	yes no	Infectious disease
yes no	Diabetes	Other:
Explain ‘yes’ items above:
Any ER visits, hospitalizations, surgeries or ongoing therapy during the last 12 months? yes no
If yes, explain and include dates:

Please list all prescription and over-the-counter medications, and reason for taking:

MEDICATIONS	HOW OFTEN	REASON FOR TAKING

List all medical equipment or assistive devices used (crutches, canes, nebulizer, CPAP, oxygen,

braces (arm/leg), wheelchair, service animals, etc.):

I have reviewed the physical requirements for my group and activity in Connection 2006-028, Deploying a Healthy Workforce and the DSHR System Handbook (with addendums) with my unit of affiliation. I understand the physical requirements for being a disaster worker and hereby state that I am able to fulfill those requirements. I understand that if my health status changes, I am responsible for updating this form immediately and submitting to my unit of affiliation.

I understand that while health insurance is NOT required, I will be financially responsible for my health care expenses.

In signing below, I give permission for the Red Cross Staff Health Reviewer to contact my health care provider for information concerning my current health status. I will be notified before contact with my health care provider is made. I understand that refusal to sign may limit deployment.

My typed signature/date is verification that information on this form is correct. Please sign form if faxing.
Signature of DSHR Member:		Date:
Signature of Health Reviewer:		Date:
Codes-Hardship/Restriction:

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American Red Cross of Huntington County
(260) 356-2910 • fax (260) 356-2111 • email: red.cross@huntington.in.us

In case of a Disaster Emergency anytime please call:

Disaster On-Call (800) 513-2599 ext.636*