Form Soc 827 - Individual Emergency Back-Up Plan
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
In-Home Supportive Services (IHSS) Program
INDIVIDUAL EMERGENCY BACK-UP PLAN
Participant Name:
Date:
Case #:
Declined to participate:
If your Care Provider does not arrive and you need assistance, call:
Family Member:
Friend:
Neighbor:
County Social Services Worker:
County IHSS Social Services Office:
Public Authority:
If you need to report abuse and/or neglect of elderly or disabled individuals, call:
Adult Protective Services:
Other important numbers:
Doctor’s Office:
Medi-Cal Office:
Advocacy Group(s):
Police Department:
Fire Department:
Other:
If you have an emergency, call 911
Social services staff discussed the above information with the recipient and/or his/her
Authorized Representative and all parties are aware of what to do in case of an
emergency.
Signature of Participant:
Date:
Signature of:
Date:
Authorized Representative, if applicable
Signature of:
Date:
County Social Services Staff
Distribution:
Original/Case File
Copy/Participant
SOC 827 (12/06)
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