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**Shelter-in-Place Information and Rules**

-   **Only essential employees are authorized to shelter at the
    MEDVAMC.**

-   **Contact your supervisor to determine your status.**

-   **All other employees are advised to follow local and state
    evacuation orders.**

**Emergency Operations Center**

  -------------------------------------- --------------------------------
  Incident Commander                     713.794.7262

  Planning                               713.794.7298/7428

  Operations                             713.794.7371

  Public Affairs                         713.794.7490

  Patient Information                    713.794.8736

  Social Work                            713.794.8553

  Safety                                 713.794.7483

  Police                                 713.794.8406

  Finance                                713.794.7598

  Logistics                              713.794.8554
  -------------------------------------- --------------------------------

National Veterans Hotline:  1-800-507-4571

VA Network Telecare Center Hotline: (713) 794-8985 or toll-free
1-800-639-5137

Employee Helpline:  1-866-233-0152

Emergency Preparedness and Response Information: www.houston.va.gov

**Rules**

1.  Only essential employees, who live in a surge zone
    (<http://www.hcoem.org/HCMap.aspx?P=Evacuation>), an evacuation zip
    code, or have *immediate* family member(s) who are unable to care
    for themselves, are authorized to have family members shelter at the
    MEDVAMC.

2.  Access to the MEDVAMC will be restricted once the MEDVAMC Director
    declares a\
    Shelter-in-Place is active. Everyone entering the MEDVAMC will be
    required to go through the check-in process at the Main Entrance.

3.  All employees must check in at the Main Entrance, if they bring
    family members or not. Employees are responsible for checking in
    with their family members and pets. You should bring your completed
    Shelter-in-Place enrollment forms (available at the end of this
    message) to the check-in. All family members and pets will be issued
    identification badges/tags to be worn at all times.

4.  At check-in, all family members over the age of 18, who do not have
    the responsibility for caring for minor children and are able, will
    be asked to assume a volunteer work assignment. Because of the
    limited number of regular staff, volunteer runners, patient escorts,
    trash collectors, and individuals to work the pet and child care
    centers are needed.

5.  Alcoholic beverages, firearms, weapons, pornography, and illegal
    drugs are prohibited by federal law on VA property.

6.  You must bring your own sleeping bags, blankets, pillows, towels,
    personal care items, toiletries, medications, and 3 days worth of
    non-perishable food items, such as peanut butter, canned fruits and
    vegetables, and ready-to-eat canned meats, for you and your family.
    These *[will not]{.underline}* be provided by the MEDVAMC.

7.  The VA Canteen will be open, but operating with limited hours and
    staff. On-duty employees have priority for food service. Family
    members should not rely on the VA Canteen for meals.

8.  Grills, hot plates, and other heating appliances are not authorized.

9.  A 10 p.m. to 6 a.m. curfew is in effect for family members. After
    this time, family members will not be allowed to loiter or wander
    the halls. This curfew will be strictly enforced by the VA Police.
    You are responsible for the behavior and misconduct of your family
    member(s).

10. A Child Care Center will be established to care for the minor
    children of on-duty MEDVAMC employees only. You must bring all
    necessary supplies including disposable diapers, formula, bottles,
    baby wipes, toys, and food for your children. Off-duty employees and
    family members are required to care for their own children.

11. A Pet Care Center will be established. Only non-aggressive household
    pets will be permitted. All animals must be housed in sturdy plastic
    or metal cages/transport containers. No cardboard or partly enclosed
    containers will be allowed. You must bring your pet's shot record
    for verification of rabies, bordello, and other essential
    vaccinations. Pets are not allowed in individual offices or on
    nursing units. There are no exceptions. Pet owners should be aware
    this order will be strictly enforced by the VA Police. You must
    bring all necessary supplies including food, water dishes,
    medications, collars, leashes, toys, and clean-up supplies for your
    pet. You are ultimately responsible for feeding, watering, walking,
    cleaning up after, and the well-being of your pet.

12. If the MEDVAMC resorts to the use of emergency power generators, all
    critical equipment, and *only* critical equipment, is authorized to
    be plugged into red outlets. Nursing Units should ensure working
    flashlights are on hand. If you have any questions, please contact
    FMSL at ext. 5884.

13. If a power outage occurs, elevator use will be limited to patient
    care activities only. Employees and family members must use the
    stairs.

14. Until an All-Clear has been announced by the MEDVAMC director, you
    are not authorized to leave the MEDVAMC. If you leave the building
    before this time, you are subject to adverse personnel action. In
    addition, you and your family member(s) will not be allowed to
    return until the MEDVAMC returns to normal operations.

15. It is mandatory for all MEDVAMC employees to wear their VA
    identification badges and family members to wear their
    identification badges at all times. Individuals not wearing
    identification and unattended children will be detained by the VA
    Police.

16. During the next few days, the MEDVAMC will keep you updated on
    personnel, patient, weather, and facility issues as information
    becomes available. In the event of a power outage, updates will be
    posted near elevator banks around the MEDVAMC. Information is also
    available by calling the MEDVAMC Automated Information Line at (713)
    794-8989 or 1-800-553-2278, ext. 8989.

17. All VA employees who are evacuated are required to check in with
    their status, location, and contact information by calling
    1-866-233-0152.  Operators are available from 7 a.m. to 7 p.m.,
    seven days a week.  You may call as soon as you have made evacuation
    plans and have contact information available or within 48 hours of
    the hurricane.

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Essential Personnel Checklist**

## *(Complete annually by April 1st and update as necessary)*

# Employee Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Service, Service/Care Line: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

**Employee Contact Numbers: Home:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Pager: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Cell:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

+---+--------------------------------------------------+---------------+
| # | #                                                | **Check and   |
|   | Essential Personnel -- Respond to the following: | Date**        |
|   |                                                  |               |
|   |                                                  | **Each**      |
+---+--------------------------------------------------+---------------+
| # | # Review the Emergency Management Section        | ** **         |
|   | and Hurricane Plan in the MEDVAMC disaster plan. |               |
| 1 |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # Revi                                           | ** **         |
|   | ew Service/Care Line Disaster Preparedness plan. |               |
| 2 |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # Staffing expectations: I h                     | ** **         |
|   | ave checked with my supervisor and know my assig |               |
| 3 | nments, per our Service/Care Line work schedule. |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # Re                                             | ** **         |
|   | ad Annual Disaster Preparedness Review document. |               |
| 4 |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # I understand that I am [not]                   | ** **         |
|   | {.underline} exempt from reporting for duty duri |               |
| 5 | ng hurricanes or other severe weather incidents. |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # Complete applic                                | ** **         |
|   | able Enrollment Forms (Family, Child Care, Pet C |               |
| 6 | are) or Exemption Form and return to supervisor. |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+
| # | # Ret                                            | ** **         |
|   | urn this form to your supervisor by April 1^st^. |               |
| 7 |                                                  |               |
| . |                                                  |               |
+---+--------------------------------------------------+---------------+

I have reviewed, and [acknowledge understanding]{.underline} of, the
items as listed above and understand that I have been designated as
"essential personnel":

## *Employee Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 

**Svc. SL/CL Executive Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **

APPENDIX

**The Michael E. DeBakey VAMC**

**Shelter in Place Plan**

**Family Enrollment Form (Essential Personnel Only)**

##  *(Complete annually by April 1st and update as necessary)*

**Essential personnel are encouraged to make other arrangements for
sheltering family members whenever the plan is activated. However, if
this is not possible, the following immediate family members will be
provided with shelter on-site: spouses, children under the age of 19,
adults with special needs who are dependent upon the employee, and other
persons approved by the Medical Center Director.**

# Employee Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

### Service/Care Line: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### Physician's Contact Information -- Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

###  Phone: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 

## FAMILY INFORMATION:  

  ----------------- -------------- --------- ------------- ----------- --------------
  Name              Relationship   Childs    Medications   Allergies   Special Needs
                                   DOB                                 

                                                                       

                                                                       

                                                                       

                                                                       

                                                                       

                                                                       

                                                                       
  ----------------- -------------- --------- ------------- ----------- --------------

If required to work when the Shelter in Place Plan is activated, I will
require on-site shelter and care for the listed individuals. In signing
this document, I affirm that I am the only adult available to care for
any dependent children listed above. I understand that I need to provide
food, supplies, and bedding for each family member listed, and that the
shelter is a non-smoking area.

## *Employee Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 

**Svc. SL/CL Executive Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **

APPENDIX

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Child Care Enrollment Form (Essential Personnel Only)**

## *(Complete annually by April 1st and update as necessary)*

Employee's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work
Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_

Cell: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pager:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Family member available to care for the child at the facility?
\_\_\_\_\_Yes \_\_\_\_\_No

If yes, name of family member:
\_\_\_\_\_\_\_\_\_­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Child's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Sex: M/F \_\_\_\_ DOB: \_\_\_\_\_\_\_\_\_\_\_

**[Requirements for Enrollment:]{.underline}**

-   **Bring a child only if you have no other alternative**

-   **Employee must provide:**

    -   Food, drinks, bottles, cups, etc., in marked containers

    -   Medication

    -   Toiletries, diapers, baby wipes, blankets, etc., for at least 3
        days

    -   Movies, toys, books, etc., for entertainment

-   **Advance registration**

    -   Supervisor to register in Database

    -   ID bands to be issued in advance (one for employee and one for
        child), listing the employee's name and work phone number and
        the child's name

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-   **Documentation that the child is current on all required
    vaccinations**

**[Medical Issues:]{.underline}**

Does your child have an ongoing medical condition? \_\_\_\_\_\_ Yes
\_\_\_\_\_\_ No

If yes, please explain:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is your child currently taking medication? \_\_\_\_\_\_ Yes \_\_\_\_\_\_
No

If yes, list schedule:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Allergies or other special requirements:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Any other comments, special needs, or requirements:]{.underline}**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\*Keep a copy of this form to bring to the Child Care Center when
utilizing it\****

APPENDIX

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Application for Exemption (Essential Personnel Only)**

## *(Complete annually by April 1st and update as necessary)*

# Employee Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Service, Service/Care
Line: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

I am requesting an exemption from working at the MEDVAMC when the
Shelter in Place Plan is activated because I meet one of the following
criteria: 

-   I provide care for an elderly immediate family member who cannot
    care for him or herself on a routine basis.  There are no other
    adult family members to provide this care.  This person would not
    otherwise qualify for a special needs shelter.

-   I provide care that cannot otherwise be delivered for an immediate
    family member who is handicapped or has a chronic illness.

-   I have a child that is less than one (1) year old.  Note: When both
    parents of a child less than one (1) year old are designated as
    essential personnel, only one parent can be granted an exemption.

-   Other\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**I certify that the above checked statement is true.  I also understand
that untrue statements may subject me to disciplinary action.**

## *Employee Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ * 

**Based on the above statement, I agree that this employee should be
granted an exemption from working at the MEDVAMC when the Shelter in
Place Plan is activated.**

**Svc. SL/CL Executive Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ **

APPENDIX

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Pet Enrollment Form -- *Canine* (Essential Personnel Only)**

## *(Complete annually by April 1st and update as necessary)*

Employee's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work
Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_

Cell: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pager:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is a family member available to care for the pet at the shelter?
\_\_\_\_\_Yes \_\_\_\_\_No

If yes, name of family member:
\_\_\_\_\_\_\_\_\_­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pet's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Breed/Sex:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Weight: \_\_\_\_

**Has the pet ever acted in an aggressive manner? \_\_\_\_ Yes \_\_\_\_
No**

**Has the pet ever bitten anyone? \_\_\_\_ Yes \_\_\_\_ No**

***If you answered yes to either question, your dog is [not]{.underline}
a candidate for the Pet Care Center.***

**[Requirements for Enrollment:]{.underline}**

-   **Bring a pet only if you have no other alternative**

-   **Employee must provide:**

    -   Crate with door

    -   Collar and leash

    -   Food and containers for at least 3 days, as well as any
        medication required

-   **Advance registration**

    -   Supervisor to register in Database

    -   ID bands to be issued in advance (one for the animal's collar
        and one for its crate), listing the employee's name and work
        phone number and the pet's name

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-   **Documentation that the pet is current on all required vaccinations
    (as of at least 48 hours prior to arrival) -- to include DPP, RV,
    and Bordetella**

**[Medical Issues:]{.underline}**

Does your pet have an ongoing medical condition? \_\_\_\_\_\_ Yes
\_\_\_\_\_\_ No

If yes, please explain:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is your pet currently taking medication? \_\_\_\_\_\_ Yes \_\_\_\_\_\_
No

If yes, list schedule:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Food Needs:]{.underline}**

Does your pet have any food allergies or food they should not eat?
\_\_\_\_ Yes \_\_\_\_ No

If yes, please list:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How often is your pet fed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Behavioral Issues:]{.underline}**

How often does your pet need to go out?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Does your pet respond to his/her name? \_\_\_\_ Yes \_\_\_\_ No

**[Any other comments, special needs, or requirements:]{.underline}**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\*Keep a copy of this form to bring to the Pet Care Center when
utilizing it\****

APPENDIX

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Pet Enrollment Form -- *Feline* (Essential Personnel Only)**

## *(Complete annually by April 1st and update as necessary)*

Employee's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work
Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_

Cell: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pager:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is a family member available to care for the pet at the shelter?
\_\_\_\_\_Yes \_\_\_\_\_No

If yes, name of family member:
\_\_\_\_\_\_\_\_\_­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pet's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Breed/Sex:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Weight: \_\_\_\_

**Has the pet ever acted in an aggressive manner? \_\_\_\_ Yes \_\_\_\_
No**

**Has the pet ever bitten anyone? \_\_\_\_ Yes \_\_\_\_ No**

***If you answered yes to either question, your cat is [not]{.underline}
a candidate for the Pet Care Center.***

**[Requirements for Enrollment:]{.underline}**

-   **Bring a pet only if you have no other alternative**

-   **Employee must provide:**

    -   Crate with door

    -   Collar and leash

    -   Food and containers for at least 3 days, as well as any
        medication required

-   **Advance registration**

    -   Supervisor to register in Database

    -   ID bands to be issued in advance (one for the animal's collar
        and one for its crate), listing the employee's name and work
        phone number and the pet's name

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-   **Documentation that the pet is current on all required vaccinations
    (as of at least 48 hours prior to arrival) -- to include FVRCP and
    RV**

**[Medical Issues:]{.underline}**

Does your pet have an ongoing medical condition? \_\_\_\_\_\_ Yes
\_\_\_\_\_\_ No

If yes, please explain:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is your pet currently taking medication? \_\_\_\_\_\_ Yes \_\_\_\_\_\_
No

If yes, list schedule:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Food Needs:]{.underline}**

Does your pet have any food allergies or food they should not eat?
\_\_\_\_ Yes \_\_\_\_ No

If yes, please list:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

How often is your pet fed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Behavioral Issues:]{.underline}**

How often does your pet need to go out?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Does your pet respond to his/her name? \_\_\_\_ Yes \_\_\_\_ No

**[Any other comments, special needs, or requirements:]{.underline}**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

***\*Keep a copy of this form to bring to the Pet Care Center when
utilizing it\****

APPENDIX

## *The Michael E. DeBakey VAMC*

**Shelter in Place Plan**

**Pet Enrollment Form -- *Non-Canine/Feline* (Essential Personnel
Only)**

**Type of Pet: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

## *(Complete annually by April 1st and update as necessary)*

Employee's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Work
Phone Number: \_\_\_\_\_\_\_\_\_\_\_\_

Cell: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Pager:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Is a family member available to care for the pet at the shelter?
\_\_\_\_\_Yes \_\_\_\_\_No

If yes, name of family member:
\_\_\_\_\_\_\_\_\_­­­­­­­­­­­­\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pet's Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Breed/Sex:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Weight: \_\_\_\_

**Has the pet ever acted in an aggressive manner? \_\_\_\_ Yes \_\_\_\_
No**

**Has the pet ever bitten anyone? \_\_\_\_ Yes \_\_\_\_ No**

***If you answered yes to either question, your animal is
[not]{.underline} a candidate for the Pet Care Center.***

**[Requirements for Enrollment:]{.underline}**

-   **Bring a pet only if you have no other alternative**

-   **Employee must provide:**

    -   Crate with door

    -   Collar and leash

    -   Food and containers for at least 3 days, as well as any
        medication required

-   **Advance registration**

    -   Supervisor to register in Database

    -   ID bands to be issued in advance (one for the animal's collar
        and one for its crate), listing the employee's name and work
        phone number and the pet's name

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-   **Documentation that the pet is current on all required vaccinations
    (as of at least 48 hours prior to arrival)**

**[Medical Issues:]{.underline}**

Does your pet have an ongoing medical condition? \_\_\_\_\_\_ Yes
\_\_\_\_\_\_ No

If yes, please explain:
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Is your pet currently taking medication? \_\_\_\_\_\_ Yes \_\_\_\_\_\_
No

If yes, list schedule:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Food Needs:]{.underline}**

Does your pet have any food allergies or food they should not eat?
\_\_\_\_ Yes \_\_\_\_ No

If yes, please list:
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How often is your pet fed?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**[Behavioral Issues:]{.underline}**

How often does your pet need to go out?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Does your pet respond to his/her name? \_\_\_\_ Yes \_\_\_\_ No

**[Any other comments, special needs, or requirements:]{.underline}**

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> ***\*Keep a copy of this form to bring to the Pet Care Center when
> utilizing it\****