Culligan Personal Emergency Evacuation Plan (PEEP)

• Site conducted

  Select

• Conducted on

  Date

• Prepared for

• Prepared by

Job Description and Location

• Description of Duties

• Job Type

  Select Warehouse Office Sales / Driver Factory

  • Warehouse
  • Office
  • Sales / Driver
  • Factory

• Normal working area

  Select Ground floor First floor Second floor Third floor Yard Warehouse areas including loading bays/pads

  • Ground floor
  • First floor
  • Second floor
  • Third floor
  • Yard
  • Warehouse areas including loading bays/pads

• Other area of work

  Select Ground floor First floor Second floor Third floor Yard Warehouse areas including loading bays/pads

  • Ground floor
  • First floor
  • Second floor
  • Third floor
  • Yard
  • Warehouse areas including loading bays/pads

Evacuation Details

• Would it help you if you were to be provided with a written emergency evacuation procedure?

  Yes

  No

  N/A

• Raise an action to a member of EHS to provide a written emergency evacuation procedure

• Do you have any problems reading and identifying the signs that mark the emergency exits and evacuation routes to the emergency exits?

  Yes

  No

  N/A

• Raise an action to a member of QSHE to provide a solution regarding signage

• Do you have any problems hearing the fire alarm(s) provided in your place(s) of work?

  Yes

  No

  N/A

• Raise an action to a member of QSHE to provide a solution regarding auditory communication

• Do you require the emergency evacuation procedures to be provided in an alternative format e.g. BSL, Braille, tape, large print etc?

  Yes

  No

  N/A

• Raise an action to a member of QSHE to provide a solution regarding alternative formats

• Would you experience any problems raising the alarm if you discovered a fire?

  Yes

  No

  N/A

• Are you likely to experience difficulties independently traveling to the nearest emergency exit for a safe and timely evacuation?

  Yes

  No

  N/A

• The assigned people should be agreed with the individual and the buddy

• Assign an evacuation buddy and deputy

• Do you find the stairs difficult to use?

  Yes

  No

  N/A

• Are you dependent on a wheelchair for mobility?

  Yes

  No

  N/A

• Are you able to transfer from your wheelchair without assistance?

  Yes

  No

  N/A

• General Comments (to include any relevant information not already identified above)

• This form should be completed for an employee who requires assistance with ANY aspect of emergency evacuation. The plan should include assistance required from the point of raising the alarm to passing through the final exit of the building

• A building layout plan should be attached to this form with routes clearly marked

  Media

Sign off

• Employee Signature:

  Sign

• I am aware of the emergency evacuation procedures and believe them to be appropriate to the needs identified above:

• Any detail you provide will be handled in confidence and stored only, with your consent, with the necessary parties required to ensure your safety and that of others

• Assessor Signature:

  Sign

• This plan must be reviewed on an annual basis (at least) and/or when any significant changes occur (of the building or employee)