【様式２】 To the Mayor

Evacuation Shelter Name

Evacuee Card

Registry Number

Date Recorded

Furigana

Address on Certificateof Residence

Homeof□Rented HomeCondition

Home□Other (Car Model:

Plate Number:Color:

Parking Location:□Yes (Livable)）－□No (Not Livable)
Do you haveany pets withyou?

CarPossible)（(date)□Totally Destroyed □Half Destroyed□Partially Destroyed/Damaged □Flooding Above Floor□Flooding Below Floor □Water Outage□Electrical Outage □Gas Outage

Is your homein livablecondition?

)/-shi-cho-muraGifu-ken□Owned Home

Manner/Location ofShelter (Multiple Answers(month)

Cell Phone Number(or Landline if noCell Phone)

HouseholdRepresentative’s Name

T yp e/(year)□Yes (Type:_______)□No *List pets in the Pet Registry.

□Evacuation Shelter □At Home □Inside of Car□Outdoor Tent (Location:) □Other (May we confirm your safety/
whereabouts to inquiring relatives?*□Yes□NoMay we put information about yourwell-being on public municipal websites?*□Yes□No)*Check Yes or No only after obtaining the agreement of allfamily members. Those who do not wish to publicize theirinformation due to domestic violence etc. must report this.

Special Circumstances (Add details about checked items below)
Care Required

MentalIntellectualDevelopmental

Other

Allergies

Medications

Other

Family Details

Expectant &Household Representative□M□Fyrs.

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□□□External □Internal□Visual □Auditory

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SexNew Mothers

NameDisabilities

AgePhysical□External □Internal□Visual □Auditory□External □Internal□Visual □Auditory□External □Internal□Visual □Auditory□External □Internal□Visual □Auditory

For Checked Items

Detailed Information
Ways You Can Contribute to Evacuation Shelter
Operations (Qualifications/Licenses/Skills)

Fill in at

Departure Date

Time ofPost-Departure

to/do-shi/-ku

Departure

Address

fu/-ken-cho,-machi/-mura,-son(year)/(month)/Contact Info(date)*Please note that the above information will be used to make a Disaster Victim Ledger in accordance with Disaster
Countermeasure Basic Act Provision 90 Section 3, and to provide information to the Evacuation Shelter Administration
Committee and administrative teams in order to operate the evacuation shelter (e.g., provide food and resources,respond adequately to special circumstances, etc.).

【様式７】

Rules for Life in the Evacuation Shelter
We hereby set the following rules for life in this evacuation shelter.
We ask all persons living in this shelter to follow these rules.

(shi/cho/mura)

Area Evacuation Shelter
Administration Committee1.

This evacuation shelter is the base of disaster management and damage mitigation in this region.
Persons using this shelter (evacuees) are asked to independently participate in the administrationof this evacuation shelter by contributing to various necessary duties.
2. In order to operate this evacuation shelter, we will organize an Evacuation Shelter Administration
Committee (henceforth “the Committee”) made up of a representative from the evacuees, as well
as a number of evacuees who will manage most of the shelter operations, the municipal employees(in charge of evacuation shelter aid), and the managers of this facility.
● The Committee will have regular meetings every day at
AM andPM.
● The Committee will include the following administration teams, made up of evacuees: the General
Affairs Team, the Evacuee Information Management Team, the Information Distribution Team, theFood & Resource Team, the Living Support Team, and the Hygiene Team.
3. When essential utilities such as electricity and water lines are restored, and living spaces aresecured for evacuees, the operations of this evacuation shelter will first be reduced and then theshelter will be closed.
4. Evacuees must fill out and submit Evacuee Cards. One card should be made out and submitted perfamily unit.
● When departing the evacuation shelter, please contact the Committee or the Evacuee Information
Management Team.
5. Areas other than those which have been permitted by the facility managers cannot be used as
shelter space. In addition, the shelter space will be regularly reviewed.
● Outdoor shoes cannot be worn inside the facilities (inside the rooms).
● Pets may only be kept in the designated area, and may not be brought into the shelter space.
6. Food and living supplies will be distributed at the Supply Distribution Space atAM andPM.
● If there are not enough food/living supplies to ensure everyone gets a share, then generally
distribution will be halted.
However, there may be instances when persons with special circumstances, having explained said
circumstances to other evacuees, may receive supplies.
● Requests for baby formula, diapers, feminine products, etc. should be made to the Food &Resource Team or the Living Support Team.
7. Lights-out will be atPM. Lights in the living space will be turned off at this time.
● To prevent crime, lights will remain on in the halls, around the toilets, and at the administrative
headquarters.
● After lights-out, please refrain from conversations or cell phone usage in the living space.
8. When the facility receives phone calls for evacuees, reception will take down messages only
between the hours ofAM andPM, and will then communicate the content of themessages via broadcast.
● During busy or crowded times, the public telephone will only be available for emergency usage.
9. Toilets will be cleaned atAM,PM, andPM. Evacuees will take turns cleaning thetoilets.
● When using flush toilets, only use the water in the buckets to flush solid waste.
10. For public health reasons, always be sure to wash your hands, gargle, and disinfect your fingers
with alcohol disinfectant when entering and leaving the evacuation shelter, and make an effort towear a mask.
● Inform the Hygiene Team if you have diarrhea, a fever, etc.
11. The drinking of alcohol inside the evacuation shelter is not permitted and neither is smoking outsideof the designated smoking areas.
12. As a general rule, fire is forbidden on the facility premises. When using heaters or cookware, first
get the approval of the facility managers, and exercise appropriate caution.
※下線部を記入のうえ、避難者の目の届くところに掲示します。
なお、内容はあくまで例示のため、状況に応じ修正してください。

【掲示様式１】

Regarding Use of the Toilets
 At present, flushing paper (such as toilet paper orflushable tissue) could block the toilet.
 Please do not flush paper down the toilet. It should bethrown away in the trash bin provided. Please ensurethat you close the lid on the trash afterwards.
 When you use the toilet, use the provided toilet flushingwater (in the bucket or plastic bottle) to flush. Everyone
must share this water, so please use it sparingly. If you
notice that the toilet flushing water is running low andwill run out soon, please cooperate and help byfetching more water.
 Because the toilet flushing water is taken from the pool,
do not use it to wash your hands. Use the waterprovided by the sink (hand washing water) to wash
your hands.
 Everyone has to share the toilets, so please keep themclean and help by tidying up if you get them dirty.
 All evacuees in the evacuation shelter will take turns
cleaning the toilet. Please check when your turn is on
the duties chart, and cooperate with everyone to get
the cleaning done.

Toilet Management岐阜県避難所運営ガイドライン様式集(英語)Ｐ

日本語

７１ 衛生的な手洗い

英語
Hygienic Handwashing

１ 流水で手を洗う

1. Rinse your hands with water.

２ 洗浄剤を手に取る

2. Take some soap in your hands.

３ 手のひら、指の腹面を洗う

3. Wash the palms of your hands and frontof your fingers.

４ 手の甲、指の背を洗う

4. Wash the backs of your hands andfingers.

５ 指の間（側面）、股（付け根）を洗う

5. Wash between your fingers and the baseof your fingers.

６ 親指と親指の付け根のふくらんだ部分を洗う 6. Wash your thumb and the skin between
your thumb and your palm.
７ 指先を洗う

7. Wash your fingertips.

８ 手首を洗う（内側・側面・外側）

8. Wash your wrists (inner side, outer side,sides).

９ 洗浄剤を十分な流水でよく洗い流す

9. Rinse off soap with a sufficient amount ofwater.

10 手をふき乾燥させる

10. Wipe your hands to dry them.

11 アルコールによる消毒

11. Disinfect your hands with alcohol.

７４ エコノミークラス症候群予防のために心掛けると Good Things to Keep in Mind forPreventing Economy-Class Syndrome
良いこと(Deep Vein Thrombosis)
予防のためには、①ときどき、軽い体操やストレッチ運動を行う②十分にこまめに水分を取る③アルコールを控える。できれば禁煙する④ゆったりとした服装をし、ベルトをきつく締めない⑤かかとの上げ下ろし運動をしたりふくらはぎを軽くもんだりする⑥眠るときは足をあげるなどを行いましょう。

In order to prevent economy-classsyndrome,1) occasionally do light exercises andstretches.
2) make sure to drink lots of fluids and stay
hydrated3) avoid alcohol. If possible, don’t smoke.
4) wear loose, comfortable clothing and donot fasten your seatbelt too tightly.
5) raise your heels up and down and lightly
massage your calves.
6) raise your legs when sleeping.

予防のための足の運動

Leg Exercises to Prevent Economy-ClassSyndrome (Deep Vein Thrombosis)

①足の指でグーをつくる②足の指をひらく③足を上下につま先立ちする④つま先を引き上げる⑤ひざを両手で抱え、足の力を抜いて足首を回す⑥ふくらはぎを軽くもむ

７６ 受付

1) Clench your toes as if making a fist withyour feet.
2) Spread out your toes.
3) Raise your heels up as you would if you
were standing on your toes.
4) Stretch your toes up while keeping yourheels on the ground.
5) Hold your knee with both hands, relax
your leg, and rotate your ankle.
6) Lightly massage your calves.
Reception

・避難所利用者名簿に世帯全員の氏名を記入してください。受付後は、避難者カードを世帯ごとに記入し、ご提出ください。
・避難所を退所されるときは、お申出ください。

７７ 避難室・Write the name of every member of yourhousehold on the Evacuee Registry. After
registration, fill in and submit one Evacuee
Card per household.
・Please report when you depart from theevacuation shelter.
Shelter Room

名称Name号室

Room Number

対象地区Area

禁煙・火気厳禁・盗難注意

No Smoking / Fire Strictly Forbidden /Beware of Theft

７８ トイレToilet

男性用・女性用

Men’s Room / Women’s Room

使用可・使用不可

Available for Use / Not Available for Use

７９ 更衣室Changing Room

男性用・女性用

Men’s Room / Women’s Room

※必ず入室前にノックをしてください！

* Always knock before entering the room!

８０ 授乳室Breast-Feeding Room

※必ず入室前にノックをしてください！
８１ 消毒Disinfectant

必ず消毒してください。
８２ ゴミ

回収時間

Always use the disinfectant.
Garbage

分別区分
可燃・不燃・（* Always knock before entering the room!

Sorting Categories）

Flammable / Inflammable /Collection Time(s)８３ 立入禁止のため立入禁止とします。

No Entry
Entry forbidden for the reason listed above.

８４ 女性専用

Women Only

８５ 喫煙所

Smoking Area

８６ 土足厳禁

No Outside Shoes Permitted※靴は靴箱へ片付けましょう。
８７ 運営本部※関係者以外立入禁止
８８ キッズスペース（子どもの遊び場）* Please put your shoes away in the shoebox.
Administrative Headquarters* Authorized Personnel Only
Kids Space(Play area for children)

８９ おむつ交換所

Diaper Changing Space

９０ 掲示板Billboard