Personal Emergency Evacuation Plan Questionnaire

Personal Emergency Evacuation Plan Questionnaire

Name
Staff Number
College/PSU
Building
Floor
Room Number
Extension
Mobile Number

The questions below relate to planning to escape in exceptional circumstances. In such circumstances you may be able to do certain things that differ significantly from what you can manage in your everyday activities. Your answers to the questions below will help us to prepare a plan in the event that we need to evacuate you in an emergency, such as a real fire.

1.  Can you provide us with information about your disability, medical condition or specific need that may affect you responding to the fire alarm/leaving a building in an emergency.

Tick as appropriate / Tick as appropriate
Mobility Impairment / Medical condition e.g. Asthma
Hearing Impairment / Temporary Impairment
Difficulty reading signage / Other – please detail below
Visual Impairment

______

______

2.  Please let us know if any of the following would be difficult for you should you need to evacuate a building when the fire alarm sounds?

Please answer and add any relevant comments
Are you able to hear the fire alarm?
Can you walk unaided down stairs?
How many flights can you manage?
How far can you walk unaided?
Do you need the use of a handrail?
Can you slide downstairs on your bottom in an emergency?
Would you be able to manage stairs if you had person/s to assist you?
How many people would you need to assist you?
How many times might you need to stop to rest?
Could your mobility be worsened by smoke?

3.  Please detail any mobility equipment you use.

Please answer and add any relevant comments
Do you use a wheelchair – if so is it manual or electric?
Will you use a wheelchair at all times that you are at university?
Are you able to tip your chair either with or without assistance to descend the stairs?
Are you able to transfer from a wheelchair to an evac chair?
/ Unaided:
Aided:
Are you able to maintain sitting balance if you are using an evac chair?
Would you be able to be transferred to a slide mat?

* If you wish to have a demo or trial of any of the above, please liaise this can be arranged

4.  Is there anything else we need to know that would make evacuating from a building difficult for you or anything that would assist you?

______

______

______

______

______

______

5.  In order that an effective PEEP can be prepared for you it may be necessary to share some of the information provided with other relevant members of Swansea University e.g. Security, Line Manager SHE Services etc.

This information will be superseded by any member of the Emergency Services, who may choose to carry out an evacuation following an assessment of the situation.

Declaration: I understand that these details will only be disclosed if they are required to meet the needs of my Personal Emergency Evacuation Plan.

Signature: ……………………………………… Date: ………………………………..