Employee Emergency & Backup Plan

Employers in the Self-Directed Supports Programs are required to have an emergency backup plan to
handle situations when an employee, who is providing essential supports, is unavailable. To ensure
backup support is available, complete the contact information below to identify friends, family, or other
natural supports, trained and qualified employees, or agency providers whom you can call for assistance.
All members of the individual's support team need to be educated about the backup plan. All emergency phone
numbers must be available to empleyees.

Primary Contacts

RelationshipNamePhone NumberAddress

Individual

Employer/Designated Rep.

Service Coordinator

Service Coordination Entity Emergency Contact

Emergency Contacts/Backup Plan

ContactNamePhone NumberAddressRelationship

1st Contact

2nd Contact

3rd Contact

4th Contact

Notes