Carer's emergency card

Anyone who provides essential support can obtain a Carer's Emergency Card, regardless of the amount of support they provide. In an emergency people will know that you are a carer and that someone relies on you.

Planning for the unforeseen

You can log your details and those of emergency contacts with us in advance. This information will form your Carers Contingency Plan.

If an emergency arises we will be able to contact a relative or other person who can step in until you are able to resume your role, or arrange alternative support. We will also be able to tell the person what support is needed and when.

Logging your details

You can record your details using the online form below to record your information. 

We will then send you a card to carry with you which is linked to these details and contains our 24 hour telephone number. 

Consent to hold details and information sharing

You will be asked on the form to give your consent for us to store this information electronically, in accordance with the Data Protection Act, for the purpose of providing assistance in an emergency. 

It will  ask you to confirm the you have obtained the consent of the person cared for to provide their contact details, which may include sensitive personal data, so that they are not left at risk in case of an accident or emergency.

You should also ensure the people who will act as emergency contacts are happy for us to hold their details.

If you are recording emergency details on behalf someone else who is a carer, please obtain their consent beforehand.

Key worker form

If you have a key worker, it is important that they complete the online key worker assessment form and submit it in conjuntion with the form on this page. 

If you are a key worker an electronic form (the equivalent of the back page of the paper form) is available on the key worker assessment page. 

You can use this form to tell Adult Care about yourself so they have the information required to support the person you care for in an emergency. More information will enable care services to better respond to your needs in an emergency.

Note: Asterisks (*) indicate required information.

Please correct the information in the fields highlighted below.

Details of carer

First name *

Surname *

House name or number *

Road or street *

Town or Village *

County *

Post code *

Telephone *

Mobile

Gender *: - - - Required selection - - - -- Select -- Male Female

Date of birth *

Ethnicity *: - - - Required selection - - - Please select your ethnicity Bangladeshi Indian Pakistani Any other Asian background (write below) African Caribbean Another Black background (write below) Chinese White and Asian White and Black African White and Black Caribbean Other Mixed Background (write below) British Irish Gypsy or Traveller Any other white background (write below) Other Ethnic (write below) I do not wish to give this information

Other ethnicity

Relationship to carer *

Details of cared for person

First name *

Surname *

House name or number *

Road or street *

Town or Village *

County *

Post code *

Telephone *

Mobile

Gender *: - - - Required selection - - - -- Select -- Male Female

Date of birth *

Ethnicity *: - - - Required selection - - - Please select your ethnicity Bangladeshi Indian Pakistani Any other Asian background (write below) African Caribbean Another Black background (write below) Chinese White and Asian White and Black African White and Black Caribbean Other Mixed Background (write below) British Irish Gypsy or Traveller Any other white background (write below) Other Ethnic (write below) I do not wish to give this information

Other ethnicity

This individual *: - - - Required selection - - - -- Select -- Is under 18 Has Mental Health needs Has a Physical disability Is 65 or over Has a Learning disability Has another condition (please specify)

Other category

Contact details of referrer

This information is required if you are not the carer

First name

Surname

Telephone

Relationship to carer

About the support you provide

Do you provide more than 14 hours of support over at least 4 days a week *: - - - Required selection - - - -- Select -- Yes No

Do you provide 24 hour supervision *: - - - Required selection - - - -- Select -- Yes No

Do you help with communication *: - - - Required selection - - - -- Select -- Yes No

Do you provide help with the following

Meal preparation, eating or drinking? *: - - - Required selection - - - -- Select -- No help required 1 to 2 times a day 3 to 4 times a day During the night All day

How many times a week do you help with meal preperation, help with eating or drinking? *: - - - Required selection - - - -- Select -- 0 1 2 3 4 5 6 7

Washing or Dressing *: - - - Required selection - - - -- Select -- No help required 1 to 2 times a day 3 to 4 times a day During the night All day

Medication *: - - - Required selection - - - -- Select -- No help required 1 to 2 times a day 3 to 4 times a day During the night All day

Trips to the toilets in the daytime *: - - - Required selection - - - -- Select -- No help required 1 2 3 4 5+

Trips to the toilets during the night *: - - - Required selection - - - -- Select -- No help required 1 2 3 4 5+

Moving round the house during the day *: - - - Required selection - - - -- Select -- No help required 1 2 3 4 5+

Moving round the house during the night *: - - - Required selection - - - -- Select -- No help required 1 2 3 4 5+

Keeping an eye on someone in the day

Keeping an eye on someone in the night

Shopping

Transport

Cleaning

Hospital and doctors appointments

Support with finances

Other help you provide

First emergency contact if you are unavailable

First name

Surname

Telephone

Mobile

Relationship to carer

Second emergency contact if you are unavailable

First name

Surname

Telephone

Mobile

Relationship to carer

GP Information for cared for person

Name of GP *

Surgery *

How caring affects your everyday life

Your ability to get a good night's sleep *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your enjoyment of your daily life *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your emotional well-being or mental health *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your ability to look after your home *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

How you spend your leisure time *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your physical health and well-being: *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your employment (paid or voluntary) *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your involvement in education or training. *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your relationship with the person you care for *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your financial situation *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your ability to meet other caring commitments (e.g. family, children etc) *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your ability to have time for yourself *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Your relationships with others who are important to you (e.g. friends, family etc) *: - - - Required selection - - - -- Select -- No or little impact Significant impact Major impact

Consent for Information Sharing

Do you consent to giving this information to Derbyshire County Council to store electronically for the purpose of providing assistance in an emergency. *

Have you obtained the consent of the person cared for to provide their contact details, which may include sensitive personal data, so that they are not left at risk in case of accident or emergency. *

I acknowledge that my information will be kept in accordance with the data protection act *

I would like to be consulted during the development of your services

If you experience any problems with this form please contact econtent@derbyshire.gov.uk and quote form ID: ILF/96