11.Evaluation form for building or industrial workplace

RECORD OF BUILDING EVACUATION

Occupational Health and Safety is required to maintain records of all emergency evacuations from University premises and buildings, regardless of cause. This information is reported to the Occupational Health and Safety Policy Committee, and in the event of any incident, can be used to show the level of training and experience building occupants have had with respect to emergency procedures and evacuations.

To this end, it is important that this form be completed as soon as possible after every evacuation, regardless of cause, and forwarded to Occupational Health and Safety. All sections of this form must be completed.

Campus
Building Name Building No.

Compiled by: Position: 

a. Evacuation Time / Date:

Day: Date: Time:

b. Cause:

Genuine Emergency: 0 Provide details in “d” below. Include how alarm was activated
False Alarm: 0 Provide details in “d” below. Include how alarm was activated
Drill 0
c. Evacuation Details:

Were any parts of the building not evacuated? Yes 0 No 0
Were any mobility-impaired people present? Yes 0 No 0
Did anyone remain in the building after the evacuation? Yes 0 No 0
Did anyone refuse to leave the building during the evacuation? Yes 0 No 0
Did the alarm system malfunction in any way? Yes 0 No 0
Were any other faults or deficiencies noted? Yes 0 No 0
(e.g. procedures inadequate, response time too long, announcements
inaudible etc)
Were there any obstructions, stored materials, equipment in exit Yes 0 No 0
corridors, exit doors or stairs?

d. Additional information, including details relating to all questions marked “yes” in “c” above, and the cause of the evacuation from “b”. Include floor numbers/room numbers where appropriate and any corrective action needed or taken.

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Please send completed questionnaire to:
Register of Building Evacuations
Occupational Health and Safety
Clayton Campus

and Zone Faculty OHS&E Committee
for your department.