Personal Emergency Evacuation Plan

This form is to be completed by disabled persons along with the ‘responsible person’ to aid in the development of a plan to evacuate the building in the event of an emergency. If you do not provide information which is necessary then you will not be able to develop a plan and subsequently you won’t be able to use the building in the safe way we would like.

If you, or the responsible person consider there to be significant issues or risks raised by this process, please contact the duty receptionist for assistance in finding suitable solutions i.e. relocating the activity you are involved in.

Name(Required)

Email(Required)

Group Name

Room Name

Floor

I am informed of a fire emergency requiring evacuation by:

Existing Alarm System

Pager Device

Visual Alarm System

Other

Please specify

Designated Assistance

Please use the plus (+) icon to add additional contacts.

Name

Contact Details

Method of Assistance

e.g. Transfer procedures, methods of guidance…

Any Equipment Provided

Evacuation Procedure

Safe Route

If you have any questions, or simply need help in completing the form then please contact the duty receptionist who will be able to assist you.

Phone

This field is for validation purposes and should be left unchanged.

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