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

     

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