Fillable Printable Emergency Action Plan Template
Fillable Printable Emergency Action Plan Template
Emergency Action Plan Template
Emergency Action Plan (Template)
EMERGENCY ACTION PLAN
for
Facility Name: ____________________
Facility Address: ___________________
DATE PREPARED: ___/_____/______
EMERGENCY PERSONNEL NAMES AND PHONE NUMBERS
DESIGNATED RESPONSIBLE OFFICIAL (Highest Ranking Manager at
_____________site, such as __________, ___________, or ____________):
Name: Phone: (________________)
EMERGENCY COORDINATOR:
Name: Phone: (______________)
AREA/FLOOR MONITORS (If applicable):
Area/Floor: Name: Phone: (_______________)
Area/Floor: Name: Phone: (_______________)
ASSISTANTS TO PHYSICALLY CHALLENGED (If applicable):
Name: Phone: (_______________)
Name: Phone: (________________)
Date ____/____/____
EVACUATION ROUTES
• Evacuation route maps have been posted in each work area. The
following information is marked on evacuation maps:
1. Emergency exits
2. Primary and secondary evacuation routes
3. Locations of fire extinguishers
4. Fire alarm pull stations’ location
a. Assembly points
• Site personnel should know at least two evacuation routes.
EMERGENCY PHONE NUMBERS
FIRE DEPARTMENT: ________________
PARAMEDICS: _______________
AMBULANCE: _______________
POLICE: ________________
FEDERAL PROTECTIVE SERVICE: ________________
SECURITY (If applicable): _________________
BUILDING MANAGER (If applicable): ________________
UTILITY COMPANY EMERGENCY CONTACTS
(Specify name of the company, phone number and point of contact)
ELECTRIC: _____________________
WATER: _______________________
GAS (if applicable): __________________________
TELEPHONE COMPANY: _______________________
Date: ___/____/_____
EMERGENCY REPORTING AND EVACUATION PROCEDURES
Types of emergencies to be reported by site personnel are:
• MEDICAL
• FIRE
• SEVERE WEATHER
• BOMB THREAT
• CHEMICAL SPILL
• STRUCTURE CLIMBING/DESCENDING
• EXTENDED POWER LOSS
• OTHER (specify)___________________________________
(e.g., terrorist attack/hostage taking)
MEDICAL EMERGENCY
• Call medical emergency phone number (check applicable):
Paramedics
Ambulance
Fire Department
Other
Provide the following information:
a. Nature of medical emergency,
b. Location of the emergency (address, building, room number),
and
c. Your name and phone number from which you are calling.
• Do not move victim unless absolutely necessary.
• Call the following personnel trained in CPR and First Aid to provide the
required assistance prior to the arrival of the professional medical help:
Name: Phone:_______________________
Name: Phone: ________________________
• If personnel trained in First Aid are not available, as a minimum, attempt to
provide the following assistance:
1. Stop the bleeding with firm pressure on the wounds (note: avoid
contact with blood or other bodily fluids).
2. Clear the air passages using the Heimlich Maneuver in case of
choking.
• In case of rendering assistance to personnel exposed to hazardous materials,
consult the Material Safety Data Sheet (MSDS) and wear the appropriate personal
protective equipment. Attempt first aid ONLY if trained and qualified.
Date___/___/___
FIRE EMERGENCY
When fire is discovered:
• Activate the nearest fire alarm (if installed)
• Notify the local Fire Department by calling .
• If the fire alarm is not available, notify the site personnel about the fire
emergency by the following means (check applicable):
Voice
Communication
Phone Paging
Radio
Other (specify)
Fight the fire ONLY if:
• The Fire Department has been notified.
• The fire is small and is not spreading to other areas.
• Escaping the area is possible by backing up to the nearest exit.
• The fire extinguisher is in working condition and personnel are trained to
use it.
Upon being notified about the fire emergency, occupants must:
• Leave the building using the designated escape routes.
• Assemble in the designated area (specify location):
• Remain outside until the competent authority (Designated Official or
designee) announces that it is safe to reenter.
Designated Official, Emergency Coordinator or supervisors must (underline one):
• Disconnect utilities and equipment unless doing so jeopardizes his/her
safety.
• Coordinate an orderly evacuation of personnel.
• Perform an accurate head count of personnel reported to the designated
area.
• Determine a rescue method to locate missing personnel.
• Provide the Fire Department personnel with the necessary information
about the facility.
• Perform assessment and coordinate weather forecast office emergency
closing procedures
Area/Floor Monitors must:
• Ensure that all employees have evacuated the area/floor.
• Report any problems to the Emergency Coordinator at the assembly area.
Assistants to Physically Challenged should:
• Assist all physically challenged employees in emergency evacuation.
Date___/___/___
EXTENDED POWER LOSS
In the event of extended power loss to a facility certain precautionary measures should
be taken depending on the geographical location and environment of the facility:
• Unnecessary electrical equipment and appliances should be turned off in
the event that power restoration would surge causing damage to
electronics and effecting sensitive equipment.
• Facilities with freezing temperatures should turn off and drain the following
lines in the event of a long term power loss.
· Fire sprinkler system
· Standpipes
· Potable water lines
· Toilets
• Add propylene-glycol to drains to prevent traps from freezing
• 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.
Upon Restoration of heat and power:
• Electronic equipment should be brought up to ambient temperatures
before energizing to prevent condensate from forming on circuitry.
• 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.
CHEMICAL SPILL
The following are the locations of:
Spill Containment and Security Equipment: ___________________________
Personal Protective Equipment (PPE):
MSDS:_____________________________________________________
When a Large Chemical Spill has occurred:
• Immediately notify the designated official and Emergency Coordinator.
• Contain the spill with available equipment (e.g., pads, booms, absorbent
powder, etc.).
• Secure the area and alert other site personnel.
• Do not attempt to clean the spill unless trained to do so.
• Attend to injured personnel and call the medical emergency number, if
required.
• 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.
Name of Spill Cleanup Company:_______________________________
Phone Number:_____________________________________________
• Evacuate building as necessary
When a Small Chemical Spill has occurred:
• Notify the Emergency Coordinator and/or supervisor (select one).
• If toxic fumes are present, secure the area (with caution tapes or cones) to
prevent other personnel from entering.
• Deal with the spill in accordance with the instructions described in the
MSDS.
• Small spills must be handled in a safe manner, while wearing the proper
PPE.
• Review the general spill cleanup procedures.
Date___/___/___
