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* 1. Date of Event

Date

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* 2. Location

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* 3. Time of Event

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* 4. Event

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* 5. Type

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* 6. Description of Emergency/Drill

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* 7. Compliance

  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.

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* 9. Analysis and Comments

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* 10. Are there areas needing improvement?

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* 11. Explain

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* 12. Corrective Action

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* 13. Corrective Action Plan

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* 14. Does personnel require additional education or training to improve performance?

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* 15. If yes, identify the needs below

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* 16. Were the actions taken accomplish the intended result?

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* 17. Name of Person Completing this Report

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* 18. Date Reviewed

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.

T