Civil Defence Assessment Checklist

This list contains information which could be useful for emergency workers or helpers if you are unable to tell them yourself. Make four copies - one to keep with your Be Ready kit; one that you can display somewhere easy to see in case someone else needs to help you; one to keep with you in case you are not at home when the emergency happens; and one to give to a friend to keep.

Sight Glasses	Good Necessary	Fair Unnecessary	Poor
Hearing Hearing aid	Good Necessary	Fair Unnecessary	Poor	Deaf
Speech	Good	Fair	Poor
Movement - able to walk:	Without Help With a Frame	With Help Not Able to Walk	With a Stick
Bathing - able to wash: - able to have a bath	Without Help Without Help	With Help With Help
Eating/drinking - able to eat:	Without Help	With Help
Sanitary needs	Don't Need Help	Need Help
I will require special help with: (give details)