Sample - Emergency Action Plan Template

• Facility Name

• Facility Address
  Address

• Prepared by

• Date prepared

  Date

EMERGENCY PERSONNEL NAMES AND PHONE NUMBERS

Designated Responsible Official

• Name

• Contact Number

Emergency Coordinator

• Name

• Contact Number

• Are area/floor monitors applicable?

  Yes

  No
Monitor

• Area/Floor

• Name

• Contact Number

• Are assistants to physically challenged applicable?

  Yes

  No
Assistant

• Name

• Contact Number

EMERGENCY REPORTING AND EVACUATION PROCEDURES

• Select type(s) of emergency to be reported by site personnel

  Select Medical Fire Severe Weather Bomb Threat Chemical Spill Structure Climbing/Descending Extended Power Loss Other (e.g. terrorist attack/hostage taking)

  • Medical
  • Fire
  • Severe Weather
  • Bomb Threat
  • Chemical Spill
  • Structure Climbing/Descending
  • Extended Power Loss
  • Other (e.g. terrorist attack/hostage taking)

• Specify

MEDICAL EMERGENCY

• Call medical emergency phone number

  Pass

  Fail

  N/A

• Select all that applies

  Select Paramedics Ambulance Fire Department Other

  • Paramedics
  • Ambulance
  • Fire Department
  • Other

• Specify

• Provide the nature of the medical emergency

  Pass

  Fail

  N/A

• Provide the location of the emergency (address, building, floor, etc.)

  Pass

  Fail

  N/A

• Provide your name and phone number from which you are calling

  Pass

  Fail

  N/A

• Do not move the victim unless absolutely necessary

  Pass

  Fail

  N/A

• Is personnel trained in CPR and First Aid available?

  Yes

  No
Personnel

• Name

• Contact Number

• Stop the bleeding with firm pressure on the wounds.

  Pass

  Fail

  N/A

• Note: avoid contact with blood or other bodily fluids.

• Clear the air passages using the Heimlich Maneuver in case of choking.

  Pass

  Fail

  N/A

• Is the medical emergency a case of rendering assistance to personnel exposed to hazardous materials?

  Yes

  No

• Consult the Material Safety Data Sheet (MSDS).

  Pass

  Fail

  N/A

• Wear the appropriate personal protective equipment.

  Pass

  Fail

  N/A

• Attempt first aid only if trained and qualified.

  Pass

  Fail

  N/A

FIRE EMERGENCY

• Is the fire alarm available?

  Yes

  No

• Activate the nearest fire alarm.

  Pass

  Fail

  N/A

• Call an notify the local Fire Department.

  Pass

  Fail

  N/A

• Notify the site personnel about the fire emergency.

  Pass

  Fail

  N/A

• Select all that applies

  Select Voice Communication Phone Paging Radio Other

  • Voice Communication
  • Phone Paging
  • Radio
  • Other

• Specify

• Fight the fire only if the Fire Department has been notified.

  Pass

  Fail

  N/A

• Fight the fire only if the fire is small and is not spreading to other areas.

  Pass

  Fail

  N/A

• Fight the fire only if escaping the area is possible by backing up to the nearest exit.

  Pass

  Fail

  N/A

• Fight the fire only if the fire extinguisher is in working condition and personnel are trained to<br>use it.

  Pass

  Fail

  N/A

• Upon being notified about the fire emergency, employees must leave the building using the designated escape routes.

  Pass

  Fail

  N/A

• Upon being notified about the fire emergency, employees must assemble in the designated area.

  Pass

  Fail

  N/A

• Designated Area Location

  Media

• Upon being notified about the fire emergency, employees must remain outside until the designated responsible official announces that it is safe to reenter.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must disconnect utilities and equipment unless doing so jeopardizes his/her safety.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must coordinate an orderly evacuation of personnel.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must perform an accurate headcount of personnel reported to the designated area.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must determine a rescue method to locate missing personnel.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must provide the Fire Department personnel with the necessary information about the facility.

  Pass

  Fail

  N/A

• The designated responsible official or emergency coordinator must perform assessment and coordinate weather forecast office emergency closing procedures.

  Pass

  Fail

  N/A

• Area/Floor Monitors must ensure that all employees have evacuated the area/floor.

  Pass

  Fail

  N/A

• Area/Floor Monitors must report any problems to the emergency coordinator at the assembly area.

  Pass

  Fail

  N/A

• Assistants to the physically challenged should assist all physically challenged employees in an emergency evacuation.

  Pass

  Fail

  N/A

SEVERE WEATHER AND NATURAL DISASTERS

• Select type(s) of severe weather or natural disaster

  Select Tornado Earthquake Flood Hurricane Blizzard

  • Tornado
  • Earthquake
  • Flood
  • Hurricane
  • Blizzard

TORNADO

• When a warning is issued by sirens or other means, seek inside shelter.

  Pass

  Fail

  N/A

• Consider small interior rooms on the lowest floor and without windows.

  Pass

  Fail

  N/A

• Consider hallways on the lowest floor away from doors and windows.

  Pass

  Fail

  N/A

• Consider rooms constructed with reinforced concrete, brick, or block with no windows.

  Pass

  Fail

  N/A

• Stay away from outside walls and windows.

  Pass

  Fail

  N/A

• Use arms to protect head and neck.

  Pass

  Fail

  N/A

• Remain sheltered until the tornado threat is announced to be over.

  Pass

  Fail

  N/A

EARTHQUAKE

• Stay calm and await instructions from the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• Keep away from overhead fixtures, windows, filing cabinets, and electrical power.

  Pass

  Fail

  N/A

• Assist people with disabilities in finding a safe place.

  Pass

  Fail

  N/A

• Evacuate as instructed by the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

FLOOD

• Where?

  Select Indoors Outdoors

  • Indoors
  • Outdoors

INDOORS

• Be ready to evacuate as directed by the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• Follow the recommended primary or secondary evacuation routes.

  Pass

  Fail

  N/A

OUTDOORS

• Climb to high ground and stay there.

  Pass

  Fail

  N/A

• Avoid walking or driving through flood water.

  Pass

  Fail

  N/A

• If car stalls, abandon it immediately and climb to a higher ground.

  Select Pass Fail N/A

  • Pass
  • Fail
  • N/A

HURRICANE

• When?

  Select A hurricane watch has been issued A hurricane warning has been issued During a hurricane

  • A hurricane watch has been issued
  • A hurricane warning has been issued
  • During a hurricane

Once a hurricane watch has been issued

• Stay calm and await instructions from the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• Moor any boats securely, or move to a safe place if time allows.

  Pass

  Fail

  N/A

• Continue to monitor local TV and radio stations for instructions.

  Pass

  Fail

  N/A

• Move early out of low-lying areas or from the coast, at the request of officials.

  Pass

  Fail

  N/A

• Collect drinking water in appropriate containers.

  Pass

  Fail

  N/A

• If you are on high ground, away from the coast and plan to stay, secure the building, moving all loose items indoors and boarding up windows and openings.

  Pass

  Fail

  N/A

Once a hurricane warning has been issued

• Be ready to evacuate as directed by the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• Leave areas that might be affected by storm tide or stream flooding.

  Pass

  Fail

  N/A

During a hurricane

• Remain indoors.

  Pass

  Fail

  N/A

• Consider small interior rooms on the lowest floor and without windows.

  Pass

  Fail

  N/A

• Consider hallways on the lowest floor away from doors and windows.

  Pass

  Fail

  N/A

• Consider rooms constructed with reinforced concrete, brick, or block with no windows.

  Pass

  Fail

  N/A

BLIZZARD

• Where?

  Select Indoors Outdoors Stranded in a car or truck

  • Indoors
  • Outdoors
  • Stranded in a car or truck

INDOORS

• Stay calm and await instructions from the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• Stay indoors.

  Pass

  Fail

  N/A

• Is there no heat?

  Yes

  No

• Close off unneeded rooms or areas.

  Pass

  Fail

  N/A

• Stuff towels or rags in cracks under doors.

  Pass

  Fail

  N/A

• Cover windows at night.

  Pass

  Fail

  N/A

• Eat and drink.

  Pass

  Fail

  N/A

• Food provides the body with energy and heat. Fluids prevent dehydration.

  Yes

  No

• Wear layers of loose-fitting, light-weight, warm clothing, if available.

  Yes

  No

OUTDOORS

• Find a dry shelter.

  Pass

  Fail

  N/A

• Cover all exposed parts of the body.

  Pass

  Fail

  N/A

• If shelter is not available, prepare a lean-to, windbreak, or snow cave for protection from the wind.

  Pass

  Fail

  N/A

• Build a fire for heat and to attract attention.

  Pass

  Fail

  N/A

• Place rocks around the fire to absorb and reflect heat.

  Pass

  Fail

  N/A

• Do not eat snow because it will lower your body temperature. Melt it first.

  Pass

  Fail

  N/A

STRANDED IN A CAR OR TRUCK

• Stay in the vehicle.

  Pass

  Fail

  N/A

• Run the motor about ten minutes each hour.

  Pass

  Fail

  N/A

• Open the windows a little for fresh air to avoid carbon monoxide poisoning.

  Pass

  Fail

  N/A

• Make sure the exhaust pipe is not blocked.

  Pass

  Fail

  N/A

• Make yourself visible to rescuers.

  Pass

  Fail

  N/A

• Turn on the dome light at night when running the engine.

  Pass

  Fail

  N/A

• Tie a colored cloth to your antenna or door.

  Pass

  Fail

  N/A

• Raise the hood after the snow stops falling.

  Pass

  Fail

  N/A

• Exercise to keep blood circulating and to keep warm.

  Pass

  Fail

  N/A

BOMB THREAT

• Be calm.

  Pass

  Fail

  N/A

• Be courteous.

  Pass

  Fail

  N/A

• Listen.

  Pass

  Fail

  N/A

• Caller's Identity Sex

  Male

  Female

• Approximate Age

• Origin of Call

  Local

  Long Distance

  Telephone Booth

• Voice Characteristics

  Select Loud High Pitch Raspy Intoxicated Soft Deep Pleasant Other

  • Loud
  • High Pitch
  • Raspy
  • Intoxicated
  • Soft
  • Deep
  • Pleasant
  • Other

• Specify

• Speech

  Select Fast Distinct Stutter Slurred Slow Distorted Nasal Other

  • Fast
  • Distinct
  • Stutter
  • Slurred
  • Slow
  • Distorted
  • Nasal
  • Other

• Specify

• Language

  Select Excellent Fair Foul Good Poor Other

  • Excellent
  • Fair
  • Foul
  • Good
  • Poor
  • Other

• Specify

• Accent

  Select Local Foreign Race Not Local Region

  • Local
  • Foreign
  • Race
  • Not Local
  • Region

• Manner

  Select Calm Rational Coherent Deliberate Righteous Angry Irrational Incoherent Emotional Laughing

  • Calm
  • Rational
  • Coherent
  • Deliberate
  • Righteous
  • Angry
  • Irrational
  • Incoherent
  • Emotional
  • Laughing

• Background Noises

  Select Factory Machines Music Office Machines Street Traffic Trains Animals Quiet Voices Airplanes Party Atmosphere

  • Factory
  • Machines
  • Music
  • Office
  • Machines
  • Street
  • Traffic
  • Trains
  • Animals
  • Quiet
  • Voices
  • Airplanes
  • Party
  • Atmosphere

• Do not interrupt the caller.

  Pass

  Fail

  N/A

• Pretend difficulty in hearing the caller so he/she keeps talking.

  Pass

  Fail

  N/A

• Is the caller agreeable to further conversation?

  Yes

  No

• Certain hour the bomb will go off

• Time remaining until the bomb will go off

• Which building is the bomb located?

• Which area of the building is the bomb located?

• What kind of bomb is it?

• What kind of package is the bomb in?

• How does the caller know so much about the bomb?

• What is the caller's name and address?

• If the building is occupied, inform the caller that detonation could cause injury or death.

  Pass

  Fail

  N/A

• Activate malicious call trace.

  Pass

  Fail

  N/A

• Hang up phone and do not answer another line.

  Pass

  Fail

  N/A

• Choose the same line and dial *57 (if your phone system has this capability).

  Pass

  Fail

  N/A

• Listen for the confirmation announcement and hang up.

  Pass

  Fail

  N/A

• Call security and relay information about the call.

  Pass

  Fail

  N/A

• Security Contact Number

• Did the caller appear familiar with the plant or building (by his/her description of the bomb location)?

  Yes

  No

• The message in its entirety and any other comments

• Notify the designated responsible official or emergency coordinator immediately.

CHEMICAL SPILL

• Spill Containment and Security Equipment Location

  Media

• Personal Protective Equipment (PPE) Location

  Media

• Material Safety Data Sheet (MSDS) Location

  Media

• Spill Type

  Large Chemical Spill

  Small Chemical Spill

When a Large Chemical Spill has occurred

• Immediately notify the designated responsible official and the emergency coordinator.

  Pass

  Fail

  N/A

• Contain the spill with available equipment (e.g., pads, booms, absorbent powder, etc.)

  Pass

  Fail

  N/A

• Secure the area and alert other site personnel.

  Pass

  Fail

  N/A

• Do not attempt to clean the spill unless trained to do so.

  Pass

  Fail

  N/A

• Attend to injured personnel and call the medical emergency number, if required.

  Pass

  Fail

  N/A

• Call a local spill cleanup company or the Fire Department (if arrangement has been made) to perform a large chemical (e.g., mercury) spill cleanup.

  Pass

  Fail

  N/A

• Name of Spill Cleanup Company

• Contact Number

• Evacuate building as necessary

  Pass

  Fail

  N/A

When a Small Chemical Spill has occurred

• Notify the designated responsible official or the emergency coordinator.

  Pass

  Fail

  N/A

• If toxic fumes are present, secure the area (with caution tapes or cones) to prevent other personnel from entering.

  Pass

  Fail

  N/A

• Deal with the spill in accordance with the instructions described in the MSDS.

  Pass

  Fail

  N/A

• Small spills must be handled in a safe manner, while wearing the proper PPE.

  Pass

  Fail

  N/A

• Review the general spill cleanup procedures.

  Pass

  Fail

  N/A

STRUCTURE CLIMBING/DESCENDING EMERGENCIES

Structure maintained by site personnel

• Structure Type

• Location (address, if applicable)
  Address

• Emergency Response Organization (if available within 30-minute response time)

• Emergency Response Organization Contact Number

EXTENDED POWER LOSS

• Unnecessary electrical equipment and appliances should be turned off in the event that power restoration would surge causing damage to electronics and affecting sensitive equipment.

  Pass

  Fail

  N/A

• Facilities with freezing temperatures should turn off and drain the fire sprinkler system in the event of a long term power loss.

  Pass

  Fail

  N/A

• Turn off and drain the standpipes in the event of a long term power loss.

  Pass

  Fail

  N/A

• Turn off and drain the potable water lines in the event of a long term power loss.

  Pass

  Fail

  N/A

• Turn off and drain the toilets in the even of a long term power loss.

  Pass

  Fail

  N/A

• Add propylene-glycol to drains to prevent traps from freezing.

  Pass

  Fail

  N/A

• Equipment that contain fluids that may freeze due to long term exposure to freezing temperatures should be moved to heated areas, drained of liquids, or provided with auxiliary heat sources.

  Pass

  Fail

  N/A

• Upon restoration of heat and power, electronic equipment should be brought up to ambient temperatures before energizing to prevent condensate from forming on circuitry.

  Pass

  Fail

  N/A

• Fire and potable water piping should be checked for leaks from freeze damage after the heat has been restored to the facility and water turned back on.

  Pass

  Fail

  N/A

• Is there personnel necessary to remain at their work areas to perform critical operations?

  Yes

  No

CRITICAL OPERATIONS

Specially Assigned Personnel

• Work Area

• Name

• Job Title

• Description of Assignment

• Remain on the site upon the permission of the site designated responsible official or emergency coordinator.

  Pass

  Fail

  N/A

• In case the emergency situation will not permit any of the personnel to remain at the facility, the designated responsible official should notify the appropriate offices to initiate backups.

  Pass

  Fail

  N/A

• Office Name/Location

• Contact Number

TRAINING

• Personnel have been trained to ensure a safe and orderly emergency evacuation of other employees.

  Pass

  Fail

  N/A

Trained Personnel

• Name

• Title

• Responsibility

• Training Date

  Date

EMERGENCY PHONE NUMBERS

• Fire Department

• Paramedics

• Ambulance

• Police

• Federal Protective Service

• Security (if applicable)

• Building Manager (if applicable)

UTILITY COMPANY EMERGENCY CONTACTS

Electric

• Name of the Company

• Phone Number

• Point of Contact

Water

• Name of the Company

• Phone Number

• Point of Contact

Telephone

• Name of the Company

• Phone Number

• Point of Contact

SIGN OFF

• Additional Observations

• Designated Responsible Official Name & Signature

  Sign

• Emergency Coordinator Name & Signature

  Sign