Pre-Emergency Plan Worksheet v1.0

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Document v1.0
  Inquiries, comments, and requests for change can be directed to: thess@casagrandeaz.gov

General Property Information

• Address
  Address

• Building Number

• Building Occupied?

  Yes

  No

• Number of Daytime Occupants

• Number of Nighttime Occupants

• Business Name

Emergency Contact

• Name

• Telephone Number(s)

• Occupancy Type

• Ground Access Obstruction(s)?

  Yes

  No

• Overhead Obstruction(s)?

  Yes

  No

• Gate Code?

  Yes

  No

• Construction Type

  Type 1

  Type 2

  Type 3

  Type 4

  Type 5

• Building Length

• Building Width

• Building Height

• Knox Box

  Yes

  No

• Knox Box Location

• Keys in Knox box verified functional and current?

  Yes

  No

Water Supply

• Hydrants (in order of preference)

Hydrant

• Location

• Distance (in feet)

• Main size

• Color / Hydrant #

Hazardous Materials

• MSDS Location

• Hazardous Materials on site?

  Yes

  No
Chemical

• Chemical Name

• Container Type

• Container Size

• Total Quantity

• UN#

• ERG Guide #

• Location of Chemical / Hazard

• Hazards of this product

• Hazardous Materials Notes:

Structure

• Primary Construction

• Stairs

  Yes

  No

• Stairwell Location

Stairwell

• Attic

  Yes

  No

• Attic Access Location

Attic Access

• Drop Ceiling

  Yes

  No

• Locations of exits other than front door

  List

  None

• Exit Locations (other than front door)

Exit

• Firewalls

  List

  None

• Firewall Locations

Firewall

• Automatic closing fire doors?

  Yes

  No

• Ventilation Locations

Roof

• Roof Shape

• Truss Material

• Roof Truss Type

• Roof Access Location

• Roof Covering

Floor

• Floor Construction

• Floor Trusses

  Yes

  No

• How many floors?

Basement

• Basement

  Yes

  No

• Basement Access Locations

Basement Access

• Basement Notes

Utilities

• Gas

  Yes

  No

• Type of Gas

• Gas Provider

• Location of Gas Shutoff

• Electricity Provider

• Location of Electrical Shutoff

• Special Electrical Hazards

  Yes

  No

• Special Electrical Hazards

Hazard

• Description of Electrical Hazard

• Location of Hazard

• Generator

  Yes

  No

• Generator Location

• Generator shut off location

• HVAC

  Yes

  No

• HVAC locations

HVAC

• HVAC Location

• Utility Notes

Suppression Systems

• Sprinkler System

  Yes

  No

• Sprinkler System Type

• Riser Room Location

• FDC Location

• Percent of Building Covered

• Sprinkler Shutoff Locked?

  Yes

  No

• Key Location (or combination)

• Standpipe System?

  Yes

  No

• Standpipe FDC Location

• Standpipe Discharge Locations

Standpipe Discharge

• Standpipe Discharge Location

• Fire Alarm System

  Yes

  No

• FACP Location

• Fire alarm reset procedure

• Fire Pump

  Yes

  No

• Fire Pump Location

• Fire Pump Capacity

• Special Extinguishing Agent

  Yes

  No

• Suppression Systems Notes

Other Information

• Notes