Personal Emergency Evacuation Plan

• Site conducted

  Select

Personal and Workspace Details

• This plan should be completed for anyone who requires assistance with any aspect of an emergency evacuation or event.
  Any details provided will be handled in accordance with the Data Protection Act 2018 (GDPR), and with your consent, consulted with the necessary parties required to ensure your safety and that of others including:
  
  • The person named on this form
  • Their line manager or host
  • Persons with designated responsibilities in an emergency event
  
  Records shall also be retained by the Health, Safety and Environment team for the purpose of compliance with fire safety laws. This plan must be reviewed at least on an annual basis and/or when any significant changes occur.
  

• Date of Assessment

• Persons Name

• Email Address

• Category of person

  Employee (Permanent)

  Employee (Temporary)

  Partner

  Contractor

  Visitor

• Line Manager Email Address

• Host(s) Email Address

• Number of days expected at location

• Has the person received an induction to the workspace to include assembly point location, types of alarm systems in use and any planned alarm tests or evacuations?

  Yes

  No

• Do you agree this personal emergency evacuation plan can be consulted with your line manager, host(s) and any other persons with designated fire duties?

  Yes

  No

• Do you find stairs and steps difficult to use?

  No

  Yes

• Do you use a mobility aid?

  No

  Yes

• Do you envisage any problems being able to transfer from your mobility aid without assistance?

  No

  Yes

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

  No

  Yes

• Do you require any emergency evacuation procedures to be provided in an alternative format e.g. BSL, Braille, Audio, Large Print?

  No

  Yes

• Please advise which format is required

  Select Audio Large Print Coloured Text / Overlay Other

  • Audio
  • Large Print
  • Coloured Text / Overlay
  • Other

• Please identify which format is required

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

  No

  Yes

• Do you envisage any issues hearing the fire alarm(s) in the workplace?

  No

  Yes

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

  No

  Yes

• Are you likely to experience any difficulties traveling independently to the nearest emergency exit and assembly point?

  No

  Yes

• Based on the information gathered in this assessment, is additional assistance required in an emergency event?

  No

  Yes

• Please detail the assistance required and persons assigned to provide this assistance

• Is a review of these arrangements required?

  No

  Yes

• Date review required