Classroom Evacuation Survey AMOT Classroom Evacuation Survey Question Title * 1. Date of Incident: OK Question Title * 2. Last name, First name: OK Question Title * 3. Email address: OK Question Title * 4. School: OK Question Title * 5. Grade Level (for multigrade classrooms, select the youngest grade level): OK Question Title * 6. Student(s) initials: OK Question Title * 7. Names(s) of any other staff members present at the time of the incident: OK Question Title * 8. What was the duration of the time you were out of your classroom? OK Question Title * 9. Were you able to continue with your instructional program in the alternate location? If not, why? OK Question Title * 10. Forms completed and submitted to administration (check all that apply) Workplace Incident Form Safe Schools Form School Generated Form OK Question Title * 11. Who responded to assist with the classroom evacuation? (Check all that apply) SERT Administrator Classroom Teacher Support Staff Member No Assistance Other (please specify) OK Question Title * 12. Has the student's behaviour resulted in a classroom evacuation in the past? Yes No OK Question Title * 13. Does the student have a behaviour plan? Yes No OK Question Title * 14. Does the student have a safety plan? Yes No OK Question Title * 15. If this student has a safety plan, were you involved in the creation/maintenance of it? (LTA) Yes No OK Question Title * 16. Does the student receive additional support in the classroom? Yes No OK Question Title * 17. Were you injured as a result of the incident that caused the classroom evacuation? Yes No If you were injured, please identify the nature of the injury OK Question Title * 18. If you answered yes to question 17, have you, or will you seek medical attention for your injury? Please note seeking medical attention requires that you AND your physician complete a WSIB form. Yes No OK Question Title * 19. Has the incident that led to your classroom being evacuated made you feel unsafe in your work environment? Yes No OK Question Title * 20. Was any of your personal property damaged as a result of the incident that led to your classroom evacuation? Yes No If your personal property was damaged, estimate the approximate value of the items that were damaged. OK If you answered YES to QUESTIONS 17, 18, 19, please call the AMOT Office at 519-522-0478 or ETFO Provincial at 1-888-838-3836 and state your call is urgent. OK DONE
