CMIST Worksheet - MAPHN.org

CMIST WorksheetTotal number of family included on this form _____.DATE: CLIENT/FAMILY NAME: COUNTY/STATE:Client location in shelter:Interviewer:This is a document to cover possible considerations for scenarios of access and functional needs. This is not an allinclusivechecklist, but rather serves as a simple guideline for referral purposes.COMMUNICATIONNEED: Access to auxiliary communicationservice Access to auxiliary communicationdevice Replacement of auxiliarycommunication equipmentMAINTAINING HEALTHNEED: Special diet Food Allergies________(type) Medical supplies and/or equipmentfor every day care (includingmedications) not related to mobility*For replacement eyeglasses or hearingaid, see Communication*For assistive mobility equipment (e.g.,wheelchair), see Independence Assistance with medical carenormally provided in the home setting Allergies ( environmental or otherhigh risk)________________(type)*For medical treatments that are notnormally provided in the home setting(e.g., dialysis), see Transportation Support for pregnant women Support for nursing mothers; Infant care availability Access to a quiet area Access to a temperature-controlledarea Mental health care (e.g., anxiety andstress management)ACTION: Provide written materials in alternative format (Braille, large and highcontrast print, audio recording, or readers) Provide visual public announcements Provide qualified sign language or oral interpreter Provide qualified foreign language interpreter Provide access to teletypewriter [TTY, TDD, or CapTel] or cell phonewith texting capabilities; pen and paper. Provide replacement eyeglasses Provide replacement hearing aid and/or batteriesACTION: Provide alternative (low sugar, low sodium, pureed, gluten-free, dairyfree,peanut-free) food and beverages; __________(diet type)Refer to Disaster Health Services to provide or procure one or more ofthe following: Replacement medication Wound management/dressing supplies Diabetes management supplies (e.g., test strips, lances, syringes) Bowel or bladder management supplies (e.g., colostomy supplies,catheters) Oxygen supplies and/or equipmentRefer to Disaster Health Services to provide assistance with one or moreof the following: Administration of medication Storage of medication (e.g., refrigeration) Wound management Bowel or bladder management Use of medical equipment Universal precautions and infection prevention and control (e.g.,disposal of bio-hazard materials, such as needles in sharps containers) Provide support by ongoing observation Provide support and/or room for breastfeeding women Assure diaper changing area is available Provide access to a quiet room or space within the shelter (e.g., forelderly persons, people with psychiatric disabilities, parents with veryyoung children, children and adults with autism) Provide access to an air-conditioned and/or heated environment (e.g.,for those who cannot regulate body temperature) Refer to Disaster Mental Health Services

CMIST WorksheetTotal number of family included on this form _____.INDEPENDENCENEED: Durable medical equipment forindividuals with conditions that affectmobility Power source to charge batterypoweredassistive devices Bariatric accommodations Service animal accommodations Infant supplies and/or equipmentACTION: Provide assistive mobility equipment (e.g., wheelchair, walker, cane,crutches) Provide assistive equipment for bathing and/or toileting (e.g., raisedtoilet seat with grab bars, handled shower, bath bench) Provide accessible cot (may be a crib, inclined head or other bed type) Provide power source to charge battery-powered assistive devices Provide bariatric cot or bedSERVICES, SUPPORT AND SELF-DETERMINATIONNEED: Adult personal assistance services Child personal assistance services*Incl. general observation and/orassistance with non-medical activities ofdaily living, such as grooming, eating,bathing, toileting, dressing and undressing,walking, etc.TRANSPORTATIONNEED: Transportation to designated facilityfor medical care or treatment Transportation for non-medicalappointment Provide area where service animal can be housed, exercised, andtoileted Provide food and supplies for service animal Provide infant supplies (e.g., formula, baby food, diapers, crib)ACTION: Identify family member or friend caregiver Assign qualified shelter volunteer to provide personal assistanceservices Contact local agency to provide personal assistance services Coordinate childcare support such as play areas; age-appropriateactivities; equal access to resources.ACTION: Coordinate provision of accessible shelter vehicle and driver fortransportation Contact local transit service to provide accessible transportationActions: No needs identified Contact Shelter Manager Contact Disaster Mental Health Services Agency, please provide agency name_____________________________________________________________________________________Other_______________________________________________________________________________Followup/Resolution/date_____________________________________________________________________________________________________________________________________________________Disaster Health Services print name/signature/date______________________________________