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1. Date of Event (Required.)

Date

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2. Location (Required.)

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3. Time of Event (Required.)

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4. Event (Required.)

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5. Type (Required.)

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6. Description of Emergency/Drill (Required.)

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7. Compliance (Required.)

  Yes No
All persons are present and accounted for
Were all persons present/compliant with the Emergency/Evacuation?
All persons met at designated area(s)
All areas checked
Did the response to the emergency require and evacuation
Evacuation completed in a timely and orderly manner

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8. Were there any injuries during the event? If "yes", then an Incident Report needs to be completed. (Required.)

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9. Analysis and Comments (Required.)

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10. Are there areas needing improvement? (Required.)

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11. Explain

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12. Corrective Action (Required.)

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13. Corrective Action Plan

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14. Does personnel require additional education or training to improve performance? (Required.)

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15. If yes, identify the needs below

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16. Were the actions taken accomplish the intended result? (Required.)

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17. Name of Person Completing this Report (Required.)

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18. Date Reviewed (Required.)

Date

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19. NOTE: This Emergency/Evacuation Report is to be completed and sent to the Executive Director or
designee following any emergency, evacuation, actual event or unannounced drill. (Required.)

T