WHS-FORM064-Ver03-Emergency Evacuation Record.doc

Emergency Evacuation Report Record Report No.: _202__/__001___...

Emergency Evacuation Report Record Report No.: _202__/__001___ ( Year / Number ) Report to Retain for a minimum of 2 years. Worksite: Date: Recorded by (Fire Warden name): First Aid Officer: _______________________ Exercise scenario:  Fire Drill / Fire  Explosion  Bomb threat  Gas leak/ air borne contaminants  Other – please specify Sequence of Events EVACUATION SEQUENCE AND YES NO N/A TIME CHECKLIST Hours Minutes Alarm activated and functioned correctly?      Warden(s) responded      Warden(s) verified emergency      Staff alerted      Evacuation commenced      Have mobility impaired persons been      evacuated? Wardens reported floor / area is clear      Wardens ensured all personnel are      present and accounted for Has the fire extinguisher been used?      Are all occupants were directed and      assisted? Are all doors were closed?      First aid officer had the first aid kit      Are Visitors counted by checking the sign      in book a) Has the situation been assessed by      the Emergency Response Team afterward? Exercise completed      Code: WHSE-FORM064-Ver03- Evacuation Report Record Last Updated: 01.10.2024 Developed by: Tony Salloum-WHS Manager Date Created: 03.10.2018 Authorised by: Simon Saba-General Manager Page 1 of 2  Emergency Evacuation Report Record Evacuation Evaluation Report Yes No N/a Comment Did staff follow proper procedures for scenario?    Was emergency confined to area of origin?    Were all areas of the office searched?    Was the designated evacuation route taken?    If not, was the most appropriate evacuation route    taken? Was the evacuation route clear of obstructions?    Did all people go to and stay at assembly point?    Did anyone re-enter the building before the all-    clear? Were emergency services liaised with?    Report No.: “000” was called by occupants _202__/__001___ Correct information given to emergency services?    ( Year / Number ) Report to Retain for a minimum of 2 years. Was an Accident/Incident/Near Miss Form    completed? Did any Wardens encounter any resistance    issues/refusal to leave? Total evacuation time: ___ _minutes & _Sec’ds______ Total occupants evacuated: _____Reported Absence (not at Work)__ __ Suggested actions to improve: Effectiveness Rating of Drill Good Fair Poor Personnel Response    Effectiveness of Procedures    Speed of Evacuation    Code: WHSE-FORM064-Ver03- Evacuation Report Record Last Updated: 01.10.2024 Developed by: Tony Salloum-WHS Manager Date Created: 03.10.2018 Authorised by: Simon Saba-General Manager Page 2 of 2  Emergency Evacuation Report Record Communications during drill    WHS Signature: ________________ Date________________, (Report is documented and Circulated) General Manager Signature: ______________________; Date: __________________ Code: WHSE-FORM064-Ver03- Evacuation Report Record Last Updated: 01.10.2024 Developed by: Tony Salloum-WHS Manager Date Created: 03.10.2018 Authorised by: Simon Saba-General Manager Page 3 of 2