Personal Emergency Evacuation Plan
Assessment
Why this form is important?
The Health and Safety at Work Act 1974, the Management of Health &
Safety at Work Regulations 1999 and the Disability Discrimination Act 1995,
place duties on you to implement effective arrangements for access and
emergency evacuation for employees and visitors. You should complete this
form so that you may establish any particular needs a relevant person may
have to enable them to safely evacuate the building.
This form is confidential.
Employee Name: Tel:
Job Title:
Department: Location:
Description of Duties
Date Completed:
1
A: Normal Place of Work
Building 1 Building 2 Building 3
Building
Floor
B: Evacuation Details
1. If your work takes you to different location in the building other than
were you are based please describe these areas.
2. Would it help you if you were to be provided with a written
emergency evacuation procedure?
Yes: No:
3. Do you require the emergency evacuation procedures to be
provided in an alternative format e.g. BSL, Braille, tape, large print
etc?
Yes: No:
4. Do you have any problems reading and identifying the signs that
mark the emergency exits and evacuation routes to the emergency
exits?
Yes: No:
5. Do you have any problems hearing the fire alarm(s) provided in your
place(s) of work?
Yes: No:
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6. Would you experience any problems raising the alarm if you
discovered a fire?
Yes: No:
7. Is anyone designated to assist you to get out in an emergency?
Yes: No: Don’t Know:
8. Are you likely to experience difficulties independently traveling to the
nearest emergency exit for a safe and timely evacuation?
Yes: No: Don’t Know:
9. Do you find the stairs difficult to use?
Yes: No:
10. Are you dependent on a wheelchair for mobility?
Yes: No:
11. If you use a wheelchair would you have problems being able to
transfer from your wheelchair without assistance?
Yes: No:
12. General Comments (to include any relevant information not already
identified above)
If you have ticked “YES” to any of the above then the Personal
Emergency Evacuation Plan in Appendix A should also be
completed
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Appendix A
Personal Emergency Evacuation Plan
This form should be completed for an employee who requires assistance
with ANY aspect of emergency evacuation. The plan should include
assistance required from the point of raising the alarm to passing through
the final exit of the building.
Any detail you provide will be handled in confidence and stored only, with your
consent, with the necessary parties required to ensure your safety and that of
others.
A copy of the completed form will be held by:
Employee
Employee’s department manager
Fire coordinator (for each building identified)
Note: This plan must be reviewed on an annual basis (at least) and/or when
any significant changes occur (of the building or employee).
A: Alarm System
1. I am able / unable to raise the alarm (delete as appropriate).
If unable to raise the alarm independently please detail agreed alternative
procedures.
2. I am informed of an emergency evacuation by:
Existing audible alarm system: Vibrating pager:
Visual alarm system: Other (please specify):
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B: Evacuation Procedure (step by step account starting when alarm
raised and finishing on final exit)
C: Designated Assistance (details of EVAC Team roles designated to
assist in executing evacuation plan)
D: Equipment Provided and its Location
5
E: Safe Routes (description of the primary and secondary escape routes)
A building layout plan should be attached to this form with routes clearly marked.
I am aware of the emergency evacuation procedures and believe them to be
appropriate to the needs identified above:
Employee Signature: Date:
Employee Name (please print):
Assessor Signature: Date:
This plan must be reviewed on an annual basis (at least) and/or when any
significant changes occur (of the building or employee).
For further help and advice, please contact: https://www.surreycc.gov.uk/people-
and-community/surrey-fire-and-rescue
