Personal emergency evacuation plan checklist
Peeps
What does this form include?
This form contains 17 sections:
General
- Where are you based for most of your time at College?
- On which days are you expected in College?
Hearing impairment
- Can you hear the fire alarm under normal circumstances?
- Do you have adequate devices to allow you to hear the alarm clearly? If 'no', please make a note below of any special or purpose designed device that could assist you in hearing the alarm more clearly.
- Are there sufficient measures in place that would assist you in leaving the building safely in the event of an emergency?If 'no', please make a note below of what additional measures could help:For example:Would visual alarm indicators help?Would written emergency procedures help?Would emergency procedures with BSL interpretation help?Would an assistant/buddy system help?
- Are you happy that all issues are covered above?If 'no', please make a note of any additional concerns below
Visual impairment
- Are you able to leave the area/building safely in the event of an emergency?
- Are you able to move around the building without aids or assistance?If 'no', please make a note of the equipment or support that you have access to - this could include use of a cane, guide dog, support worker etc
Mobility impairment
- Can you leave the building unassisted?If 'no' what support is necessary to assist you?This could include:Use of a wheelchair, or use of a support person etc
- If you use a wheelchair, are you able to leave the chair and move short distances if required?
- Is your wheelchair a standard size and able to fit through standard size doors?
- Have you ever been shown how an evac chair operates to assist you in leaving the area in an emergency?If 'no', please make a note below to provide information about:Would you be able to use a chair if required?Would you like a familiarisation session to show you how they work?
- Has the concept of 'fire refuge points' been explained to you?
- If necessary, would you find it acceptable to use a fire refuge point?
- Do you have access to a support person or buddy who would assist you and stay with you in an emergency?
- Are there sufficient measures in place to assist you in leaving the area in the event of an emergency? If 'no', please make a note below of any additional measures that you feel would assist you.These could include: relocation of the class to a ground floor level, implementing buddy systems, provision of emergency procedures in a format suitable to the individual, per-planning emergency evacuation routes.
- Are you happy that all issues have been covered above?If 'no', please make a note below of any additional concerns that you may have.
Tour of the work area/building that you most commonly use.
- Is the directional and instructional signage adequate and relevant?
- (if you have a hearing impairment) - are there illuminated alarm devices within the toilet areas that you would use?
- (if you have a partial mobility or visual impairment) - do you routinely negotiate stair wells and/or lifts?
- If you use stairs, are the edges of the treads of the stairs adequately identified?
- If you use lifts, is there easy access/egress from the lift and is the lift easy to operate?
- If you use a lift, is there an emergency telephone or other communication method installed in the lift?
- There will be fire doors with self closing devices on your exit routes - are you able to negotiate these doors without too much hindrance?
- If there are internal or external steps on your exit route, can you negotiate these without too much hindrance?
If at this stage you have decided that you do not want a Personal Emergency Evacuation Plan please sign the statement below:
Staff Member
Type name and sign
PEEP - summary
This PEEP belongs to: (include the staff/student ID number, contact details and the course being stud
I will be informed of an evacuation by:Existing alarmVisual alarm systemBuddy/support systemOther....
The following persons have been designated to provide assistance to help me exit the building in an e
The following procedure will be followed: ( from the discovery of a fire - to the alarm activation -
The following training/practice requirements have been identified:
A copy of my PEEP has been provided too:
PEEP accepted by:
Use this template