Emergency Evacuation Assessment
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Unique Document Referance Number (Auto Completed)
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Site conducted
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Assessment Date
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Employee Name
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Employee Job Title
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Line Manager
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Department
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Mobile Telephone Number
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Desk Phone Extension Number
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Email Address
Personal Evacuation Assessment
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Would a written personal evacuation procedure help you in a fire evacuation event
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Do you require fire safety information in an alternate format (For example, Braille, largeprint, audio, BSL, or another language.)
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Prefered Language
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Do you have any problems reading and identifying emergency signs on evacuation<br>routes and emergency exits
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Do you have any problems hearing fire alarms
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Would you have any difficulty raising the alrm if you discovered a fire
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Would you struggle to travel independantly and quickly to the nearest emergency exit
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Do you have any difficulties using stairs
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Do you require the use of a wheelchair for mobility
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Type of wheelchair required
Assessment Completion
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Assessors Name and Signature
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Does the employee required a Personal Emergency Evacuation Plan (PEEP)
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What duration is a Personal Emergency Evauation Plan (PEEP) required
Approval
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Responsible Person required for PEEP
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Date and time of approval
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Approver's signature
