Emergency Evacuation Drill – Evaluation Form

Person Completing Day & Date:

Form / Title: Hari &Tanggal:
Penanggung jawab
formulir / Jabatan:

Time Alarm Sounded: Time Drill Concluded: Time to Evacuate:

Jam Alarm dibunyikan: Jam sudahselasai: Berapa lama
prosesnya:

Type of Drill–Jenis Latihan: Notification / Alert Method: Weather Conditions:

Metode Pemberitahuan Siaga: Kondisi Cuaca:

X Fire / Evacuation - Evakuasi  Bell or Buzzer – Bel X Clear - Cerah

 Lockdown - Penyanderaan  Intercom/Radio - Radio  Cloudy – Berawan
 Modified Lockdown –  Phone – telpon/hp  Light Rain – Gerimis
Penyanderaantermodifikasi  Voice Notification –  Rain - Hujan
 Shelter-in-Place - PengumumanSuara  Heavy Rain – Hujan Deras
 Earthquake – GempaBumi X Siren - Sirena  Rain and wind – Huja berangin
 Tsunami - Tsunami X KulKul – KulKul  Windy–Berangin
 Medical Emergency –  Other- Lainnya:  Other – Lainnya:
KeadaanDaruratMedikal ______________________ ________________________
 Weather Emergency –
KeadaanDaruratCuaca
 Other - Lainnya:
_________________________

Participants: (check all that apply) Situation at Start of Drill: Gathering Area Used:
Peserta: (pilih semua yang sesuai) Keadaan sebelum latihan: Tempat Berkumpul:

 Senior Management – Managemen  Before School Hours – Sebelum  Sports Field - Lapangan
 Employees/Staff – Karyawan jam masuk sekolah  Gymnasium – Ruang Olah
 Security Staff – Sta fSekurity  During School Hours – Jam Raga
 Students – Siswa masuksekolah  Designated Off-Campus site –
 Parents/Visitors – Orang Tua/Tamu  Break Time – Jam istirahat Tempat yang ditunjuk di luar
 Contractors – Kontraktor  Lunch Time – Jam makansiang kampus
 Law Enforcement – Polisi  After Business Hours – Setelah  Other - Lainnya:
 Banjar security - Pecalang jam jekolah ______________
 Fire Department – Departamen  Other - Lainnya:
Pemadam Kebakaran _______________
 Emergency Medical Services - _____________________
Ambulan
 Other – Lainnya:
___________________

Management previously trained on Employees previously trained on

emergency procedures this year? emergency procedures this year?
Managemen sudah dapat latihan Karyawan sudah dapat latihan
prosedur2darurattahunini? prosedur darurat tahun ini?

 Yes - Ya  Yes - Ya
 No - Tidak  No - Tidak

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Revised Sep, 2014
 Emergency Evacuation Drill – Evaluation Form

Problems Encountered – Masalah yang ditemukan: (Check all that apply)

 Congestion in walkways – Macet di jalan kaki
 Alarm not heard – Suara Alarm tidak didengar
 Employees unsure of what to do / proper – Karyawan
kurang pasti prosedur
 Staff unsure of responsibilities / response – Karyawan
kurang paham akan tangungjawab
 Weather-related problems – Masalah Cuaca
 Difficulties with evacuation of disabled personnel or
visitors –Kesulitan dalam mengevakuasi orang denga
nketerbatasan fisik
 Personnel/Student unaccounted for (note # below) –
Staf/Murid tidak ditemukan (catat berapa orang di
bawah)
 Radio communication problems – Masalah Komunikasi
Radio
 Network / computer problems – Masalah
computer/network
 Noise impedes communications - Kebisingan
 Personnel/Students not out of sight (lockdown drill) –
Staf/Murid masih kelihatan
 Long time to evacuate buildings – WaktuEvakuasi
terlalu lama
 Personnel not serious about drill – Staf kurang serius
 Improper or unavailable supplies (SiP) –
Keterbatasan/Ketidaktersediaan peralatan
 Confusion - Kebingungan
 Transportation – Masalah transportasi
 Other - Lainnya: ____________________________
__________________________________

Extenuating Circumstances / Identified Factors / Special Conditions Simulated:

Keadaan Luar Biasa / Factor Teridentifikasi / Simulasi Kondisi Spesial:

Plans for Improvement:(check all that apply and explain below)

Rencana Perbaikan: (pilih semua yang sesuai dan menjelaskan dibawah)

 Additional management training – Pelatihan  Cooperative planning with responders –

tambahan untuk manajemen Mengkordinasikan untuk bekerjasama
 Additional staff training – Pelatihan tambahan dengan pihak terkait dengan kegiatan ini
untuk Staf  Revised emergency procedures –
 Address need for additional equipment – Perubahan prosedur Keadaan Darurat
Penambahan peralatan  Other = Lainnya:
 Improved emergency supplies –
Meningkatkan persediaan peralatan darurat.

Recommendations – Rekomendasi:

____________________________________________ _________________________________
Signed: Date: