Personal Emergency Evacuation Plan Questionnaire for Disabled Staff

Transcription

1 Personal Emergency Evacuation Plan Questionnaire for Disabled Staff 1. Why you should fill in this form. As your employer, Network Rail has a legal responsibility to protect you from fire risks and ensure your health and safety at work. To do this properly we need to know: a) If you require information about our emergency egress procedures: b) If you need assistance during an emergency. 2. What will happen when you have completed this form. We will be able to provide you with any information you need about the emergency egress procedures in the building(s) in which you work. If you need assistance, we will be able to work out a Personal Emergency Egress Plan for you. To do this we will discuss the best ways of getting you out quickly and comfortably. We will involve you, your manager or supervisor and the person in charge of the building(s) in which you work. (It shouldn t take you more than a few minutes to complete this form). Name Job Title Department Brief description of duties (include agile working and any requirements to visit other NR buildings) Annex A Page 1 of 6

2 3. Location I. Where are you based for most of the time? Please name the building, the floor and the room name/number. Will your job take you to more than one location in the building in which you are based? I Will your job take you to different buildings? 4. Awareness of Building Emergency Egress Procedure I. Are you aware of the emergency egress procedures, which operate in the building(s) that you work in? *If your answer is no for any of the buildings where you work please list them here. Do you require written emergency egress procedures? I Do you require written emergency egress procedures in an alternative accessible format? *If your answer is yes please indicate which format you prefer a) Supported by sign language interpretation b) Braille c) Audio d) Large Print Annex A Page 2 of 6

3 IV. Are the signs, indicating the emergency exits and the routes to the exits clear enough? *If your answer is no for any of the buildings where you work please list them here. 5. Emergency Alarm I. Can you hear the fire alarm(s) provided in your place(s) of work? *If your answer is no for any of the buildings where you work please list them here. Could you raise the alarm if you discovered a fire? 6. Assistance I. Do you need assistance to get out of your normal place of work in an emergency? Yes/ No/ Do not Know (Please indicate) If no go to question 18. Is anyone designated to assist you to get out in an emergency? If yes give name(s) & location(s) If no go to question 17. I Is the arrangement with your assistant(s) formal? Yes/ No/ Don t Know (Please indicate) Annex A Page 3 of 6

4 IV. Are you always in easy contact with those designated to help you? Yes/ No/ Don t Know (Please indicate) V. In an emergency, could you contact the person(s) in charge of evacuating the building(s) in which you work and tell them where you are located? Yes/ No/ Don t Know (Please indicate) 7. Getting Out I. Can you move quickly in the event of an emergency? Do you find stairs difficult or impossible to use? I Are you a wheelchair user? IV. I wish to be consulted about any plan for my evacuation in case of an emergency. Thank you for completing this questionnaire. The information you have given will help us to meet any needs for information or assistance you may require. Please add any other comments below which you feel may assist us in designing your personal emergency egress plan (you need not supply any personal or medical information unless you wish to do so. Any such information you do supply will be used purely for this purpose and remain confidential). Please return the completed form to your line manager... Annex A Page 4 of 6

5 Personal Emergency Evacuation Plan Name: Location: Building: Floor : Room No: Awareness of Procedure I am informed of an emergency evacuation by: Existing Alarm Pager Device Visual Alarm System Other (please specify) Designated Assistance The following people have been designated to give assistance when I need to get out of the building in an emergency. Annex A Page 5 of 6

6 Methods of Assistance: (Transfer procedures, methods of guidance, etc.) Equipment Provided: Egress Procedure 1 : (A step-by-step account, beginning from the first alarm). Safe Route(s): (Include diagram if required). Date Completed: Next review: 1 This should be tested to ensure the plan will work in an emergency Annex A Page 6 of 6