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Emergency Action Plan Sheet Template

This template is used to automatically create and distribute to emergency personnel names and phone numbers, emergency phone numbers, utility contacts for emergencies, emergency reporting and evacuation procedures, and training.

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Emergency Action Plan Sheet Template

Emergency Action Plan Sheet

Emergency Staff

Employee in charge

Name

Contact number

Emergency Coordinator

Name

Contact number

Are area/corridor monitoring devices applicable?

Area/corridor

Name

Contact number

Are helpers for physically disabled people available?

Name

Contact number

Emergency Notification and Evacuation Procedures

Select the type(s) of emergency to be reported by local staff

Medical Emergency

Call the telephone number for medical emergencies

Specify the nature of the medical emergency

Indicate the location of the emergency (address, building, floor, etc.)

Enter your name and the telephone number from which you are calling.

Only move the victim when absolutely necessary.

Is first aid trained personnel available?

Name

Contact number

Does the medical emergency involve assistance to personnel who come into contact with hazardous materials?

Fire Emergency

Is the fire alarm available?

Only fight the fire if the fire department has been notified.

Fight the fire only if the fire is small and does not spread to other areas.

Fight the fire only if escape from the area is possible by going back to the nearest exit.

Fight the fire only when the fire extinguisher is in working order and personnel are trained to use it.

After being notified of the fire emergency, staff must leave the building using the designated escape routes.

After notification of the fire emergency, employees must gather in the designated area.

Location of the designated area

After notification of the fire emergency, employees must remain outside until the designated responsible employee announces that re-entry is safe.

The responsible officer or the emergency coordinator shall disconnect supply lines and equipment unless this would compromise his or her safety.

The responsible officer or the emergency coordinator shall coordinate an orderly evacuation of personnel.

The employee responsible or the emergency coordinator must establish a rescue method to locate missing personnel.

The employee in charge or the emergency coordinator must provide the fire service personnel with the necessary information about the facility.

The responsible staff member or the emergency coordinator shall make an assessment and coordinate the emergency closure procedures of the meteorological report service.

The area/corridor supervisors shall ensure that all staff have evacuated the area/corridor.

The area/corridor monitors shall report any problems to the emergency coordinator in the meeting area.

Disabled assistants should assist all physically disabled employees in an emergency evacuation.

Weather and Natural disasters

Select the type(s) of storm or natural disaster

Hurricane

If a warning is given by sirens or other means, seek shelter.

Consider small interior spaces on the lowest floor and without windows.

Consider corridors on the lowest floor away from doors and windows.

Consider rooms built of reinforced concrete, bricks, or blocks without windows.

Stay away from exterior walls and windows.

Use arms to protect head and neck.

Stay protected until the end of the threat is announced.

Earthquake

Remain calm and wait for instructions from the designated responsible officer or the emergency coordinator.

Stay away from ceiling fixtures, windows, filing cabinets and electricity.

Help people with disabilities find a safe place.

Evacuate on the instructions of the designated responsible officer or emergency coordinator.

Flood

Where?

Indoor

Be prepared to evacuate on the instructions of the emergency coordinator in charge.

Follow the recommended primary or secondary evacuation routes.

Outdoor

Climb to a hill and stay there.

Avoid walking or driving through high water.

If the car stops, leave it immediately and climb to a higher place.

Stranded in a Car or Truck

Stay in the vehicle.

Run the engine for about ten minutes every hour.

Open the windows for a little fresh air to avoid carbon monoxide poisoning.

Make sure the exhaust pipe is not blocked.

Make yourself visible to the rescuers.

At night, turn on the dome light when you leave the engine running.

Tie a coloured cloth to your door or antenna.

Raise the hood when the snow stops falling.

Exercise to keep the blood circulating and warm.

Bomb Threat

Stay calm.

Be polite.

Listen.

Caller identity/gender

Approximate Age

Origin of the call

Characteristic of the voice

Speech

Language

Accent

Style

Do not interrupt the caller.

Pretend that you are having trouble hearing the caller so that he/she continues speaking.

Background Noises

Does the caller agree to another conversation?

Did the caller seem familiar with the facility or building (based on his/her description of the bomb location)?

The message in its entirety and any other comments

Notify the responsible emergency coordinator immediately.

Chemical Waste

Place of containment of leaks and safety equipment

Personal protective equipment (PPE) Location

Location of the Material Safety Data Sheet (MSDS)

Burial type

When a major chemical spill has occurred

When a minor chemical spill has occurred

Emergencies during Ascent and Descent of Structures

Infrastructure maintained by site personnel

Infrastructure type

Location (address, if applicable)

Crisis response organisation (if available within 30 minutes response time)

Emergency response organisation contact number

Extended Losses of Power

Unnecessary electrical equipment and appliances should be switched off if restoring power would cause a power surge that would damage electronics and affect sensitive equipment.

Equipment with temperatures below freezing should be shut down and the sprinkler system drained in the event of a long-term power failure.

In the event of a long-term power failure, the standpipes should be switched off and emptied.

In the event of a long-term power failure, the drinking water pipes should be switched off and emptied.

Switch off and empty the toilets in case of a long-term power failure.

Add propylene glycol to the drains to prevent the traps from freezing.

Equipment containing liquids that can freeze due to long-term freezing temperatures should be moved to heated areas, drained of liquids or provided with auxiliary heat sources.

After heat and power have been restored, electronic equipment should be brought to ambient temperature before being switched on to prevent the formation of condensation on the circuits.

Fire and drinking water pipes should be checked for leaks due to frost damage after the heat has been returned to the system and the water has been switched on again.

Is it necessary for personnel to remain at their place of work to perform critical operations?

Critical Operations

Specially assigned personnel

Workspace

Name

Job title

Description of the assignment

Remain on-site if approved by the responsible emergency coordinator designated by the site.

If the emergency situation does not allow any of the personnel to remain in the facility, the designated responsible person should notify the competent authorities to initiate safety measures.

Training

The staff was trained to ensure a safe and orderly emergency evacuation of other employees.

Name

Title

Responsibility

Date of the training

Emergency Phone Numbers

Fire department

Paramedics

Ambulance

Police

Federal Protection Service

Security (if applicable)

Building Manager (if applicable)

Emergency Contacts of the Supply Companies

Electrical

Name of the company

Phone number

Contact person

Water

Name of the company

Phone number

Contact person

Phone

Name of the company

Phone number

Contact person

Sign-off

Additional observations

Designated responsible official name

Signature

Name of the emergency coordinator

Signature

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.