Evacuation Checklist

This form was not completed correctly. Please review the items in red.

Section 1 - Emergency Details

Name (of person reporting): *

Role/Title: *

Phone number: *

Email Address: *

Building name/code: *

Date of Emergency Evacuation *

/
day

month

year

Area of building affected: *

Entire Building

Specific area (please describe below):

Specific area affected:

Level of Occupancy: *

Full Staff/Student Load

Staff Only

After-Hours

Type of Evacuation: *

Unplanned alarm activation (please describe below)

Real Emergency (please describe below)

Planned evacuation exercise

Details of unplanned alarm activation/real emergency evacuation:

Section 2 - Evacuation Sequence of Events (use 24 hour time or give details)

Alarm activation (when alert tone sounded): *

Evacuation commenced (when evac tone sounded): *

First warden reported to Chief Warden/Security: *

Last warden reported to Chief Warden/Security: *

Wardens guard entry points and move occupants to assembly area: *

Evacuation completed: *

Emergency declared over: *

Evacuation Debrief/Evaluation:

Did all Wardens report to the Chief Warden? *

If No, which Wardens did not report?

Were perimeter entrances guarded to prevent re-entry? *

If No, specify area/s that were not guarded....

Did Wardens use emergency equipment (eg WIP, EWIS) competently? *

If No, please provide relevant details....

Could Alarm be heard throughout the building? *

If no, please specify area/s....

Were the Public Address announcements clear and audible? *

If No, please specify details....

Were Emergency Exits clear and operational? *

If No, please specify area/s and problem/s....

Were Exit paths well lit?

If no, please specify areas....

Were all occupants evacuated? *

If No, who did not evacuate....

Was/were the relevant Supervisor/s notified that not all occupants evacuated? *

Were any mobility, vision or hearing impaired occupants present? *

If yes, have specific procedures been established and discussed with the people involved?

If you have any other comments regarding the evaluation of this evacuation, please outline them here....

Corrective Action/s

Please outline any recommended action/s, stating who is responsible for their implementation and the due by date of implementation.

Action 1

Action 2

Action 3

Action 4

Action 5

User Agreement

I confirm that facility related actions, including problems with emergency exits, lighting or alarms, will be reported to the CIS Service Desk within 24 hours. *

I confirm that any procedural actions will be reported to the Chief Warden or relevant Head(s) of School, Department or Unit (as appropriated) within 24 hours, for their action within 14 days. *

The University of Sydney - Work Health & Safety

Section 1 - Emergency Details

Section 2 - Evacuation Sequence of Events (use 24 hour time or give details)

Evacuation Debrief/Evaluation:

Corrective Action/s

User Agreement