Emergency Action Plan - Smith & Associates

Date *

Company Name *

Company Phone Number *

Name of Person Completing This Form *

First

Last

Phone Number of Person Completing This Form *

Email Address of Person Completing This Form *

Project Name *

Project Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is the project site in a community-based settings or high-crime area? Verify with local police or apps (www.CrimeMapping.com, etc.) *

Please select the categories of crimes identified for the project site. *

Please select all that apply. To select multiple items, hold the shift or command key down.

Who will be responsible for this emergency action plan (updates, etc.)? *

First

Last

Phone Number of Person Responsible *

Onsite Emergency Coordinator Name and/or Title *

Cell Phone Number of Onsite Coordinator *

Backup Onsite Emergency Coordinator Name and/or Title *

Cell Phone Number of Backup Coordinator *

Personnel (titles) Emergency Action Assignments/Responsibilities (area sweeps to confirm that all personnel have evacuated the work area locations, First Aid/CPR, headcounts, etc.): *

Is there another phone number that is needed to go through to dial 911 from a landline? *

What is the number sequence?

Project area Electric Company Name *

Electric Company Emergency Phone Number *

Project area Gas Company Name *

Gas Company Emergency Phone *

Project area Water Company Name *

Water Company Emergency Phone Number *

Other Utilities

Phone Numbers of Other Utilities

Other(s) that will need to be contacted in the event of an emergency (upload flow cart and phone numbers if applicable):

Emergency Contact Flow Chart (if applicable)

Click or drag a file to this area to upload.

10 MB Max File Size

Fire Extinguisher Location *

First Aid Kit / Eye Wash Locations *

Describe the evacuation assembly areas and routes (attach maps if available)

Evacuation Route Maps (if available)

Click or drag a file to this area to upload.

10 MB Max File Size

What will the process be to account for all employees after emergency evacuation has been completed (headcount, who will do this, what action will take place if someone is missing, who will be called, who will release everyone once the headcount is completed, etc.)? *

What will the process be for personnel performing rescue or medical duties (who and how will they be contacted, etc.)? *

The Grab & Go Medical Facility Information will be located (readily available) *

What type of Severe Weather events including earthquakes may happen at your jobsite location? *

During a power outage, what type of resources will be available to employ and back-up resources if necessary? *

Chemical Spill - Small or Low Hazard, Indoors or Outdoors – Spill Kit Locations *

Safety Data Sheets Location(s) *

How will personnel be notified of an emergency and to evacuate (air horn, verbal, radio, alarms, etc.)? *

How should employees respond to workplace violence occurrences? *

How should employees report suspicious persons or activities? *

Do non-employees have access to and freedom of movement within the project site and work areas? Please explain. *

Are there adequate security systems (door locks, security windows, physical barriers) to prevent access to project work areas? Please explain. *

What system will be used to notify employees of security dangers or to summon assistance (alarms, panic buttons, etc.)? *

Will a "buddy" system be used for emergency events? *

Please explain the "buddy" system process. *

Are there emergency escape routes? *

Please describe the escape route locations. *

How is the Workplace Violence Prevention Plan communicated to employees, supervisors, and managers? *

How should employees communicate concerns regarding workplace violence? *

Are there hiding spots for the public (outside the project site, parking lot, etc.)? Please explain.. *

Is there a parking lot? *

Is there a parking lot attendant or secured parking? *

Are project site windows clear of obstructions? *

Are visitor procedures in place, such as badges or sign-ins to identify non-employees? *

If applicable what are the Site-Specific Protocols that need to be included?

If applicable what are the procedures that need to be followed for personnel that remain behind to operate critical operations before they evacuate?

Training: All employees will be trained to the emergency action plan. This will include Annually, for New Hires or when there are changes to the plan.

Please prove your a human. *

What is the last letter of the alphabet?