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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
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.
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