Title Page
-
Conducted on
-
Prepared by
-
Location
Employee Awareness - sample by asking people the following questions
-
Does the employee recall participating in an emergency drill in the past twelve months?
-
Can the employee recall the drill’s scenario? (Eg: Evacuation, Medical Emergency, Shelter in place, chemical spill, etc.)
-
Does the employee know where and how to report emergencies (activate an alarm pull station, telephone, radio, etc.)?
-
Has the employee been trained to recognize emergencies (fires, chemical spills, injury, etc.)?
-
Does the employee know where to go (assembly point)?
-
Can the employee identify where the evacuation map is located and where their closest exit is from anywhere in the facility?
Site Conditions - Walk and verify
-
Are evacuation route maps posted in all occupied buildings on all floors?
-
Are exit routes free of obstructions?
-
Are exit signs visible and illuminated?
-
Is emergency egress lighting adequate, and in working order?
-
Does the site maintain a first aid kit by conducting regular inspections and utilizing a log of items taken?
-
Is the first aid kit medications within the expiration dates?
AED Check
-
Check the box if the location has an AED onsite. If this question is Not Applicable, then proceed to the next section
-
Are there appropriate persons trained on-site for the use of the AED?
-
CPR mask inside?
-
Safety razor available for use of the pads?
-
Scissors for emergency removal of clothing avalible?
-
Gloves avalible?
-
Electrodes and batteries in date?
Pictures
-
Please upload any best practices or verification photos (Examples could include Exits free of blockage, Signage illuminated, Roster/Evaluation sheet of last emergency drill, etc)
-
Please upload any opportunities to improve photos related to emergency response.
-
You can type any comments about your Emergency Response Gemba here:
-
Add signature
