PERSONAL EMERGENCY EVACUATION PLAN

QUESTIONNAIRE

Name of Student:

Date:

Mobility or medical needs

Can you leave the building unassisted? Y N NA

Do loud noises make you startle? Y N NA

Can you move quickly in the event of an emergency? Y N NA

Distance
How far can you walk unaided?

Can you manage a flight of stairs? Y N NA

Can you manage a small number of steps? Y N NA

Are you a wheelchair user? Y N NA

Do you use the wheelchair all the time? Y N NA

Can you manage without the wheelchair for short periods of time? Y N NA

Is your wheelchair a standard size or larger? Stand Large NA

Is it an Electric Wheelchair? Y N NA

Is it an Attendant Propelled? Y N NA

Can you propel yourself in an emergency? Y N NA

Are you happy to stay in a safe refuge point until collected? Y N NA

Could you walk down a flight of stairs with one assistant holding
Y N NA
each arm?
Could you walk down a flight of stairs with one assistant and the
Y N NA
use of a handrail?
Could you be supervised to walk down the stairs unaided once the
Y N NA
majority of people had already left?
If someone was with you would you be able to move down a flight
Y N NA
of stairs on your bottom, unaided?
Could you self transfer to and evacuation chair or stair climber? Y N NA
Would you need additional equipment to transfer (i.e. a banana
Y N NA
board, handling belt etc)
Would your medical condition prevent you being lifted by a trained
Y N NA
fire fighter?
Would your medical condition prevent you from using an
Y N NA
evacuation chair or stair climber?
Do you know who is assigned to you in case of an emergency? Y N NA

Are there any other problems/observations or solutions you can Details

think of?

Deaf or Hearing Impaired

Would you be able to hear the fire bell or an announcement to say
Y N NA
there was an emergency?
Would you find a visual indicator useful? Y N NA

Would you like someone to help you evacuate the building? Y N NA

Would you find a vibrating pager useful which warned you there
Y N NA
was a fire alarm?
Are there any other problems/observations or solutions you can Details
think of?

Blind or Visual Impairment

Would you be able to safely leave the premises in the event of an
Y N NA
emergency?
Can you see and read the signage clearly? Y N NA

Can you see and read the emergency escape instructions clearly? Y N NA
Do you require help or equipment to move around the building
Y N NA
(person, cane or dog etc)
Could you find your way out of the building if your normal route
Y N NA
was not longer available?
Would you be anxious evacuating the building if you were in a
Y N NA
crowd of other people?
Would you prefer to have an assistant help you out of the building
Y N NA
in case of an emergency?
Would you be happy to leave the building after the majority of
Y N NA
other people had left?
Would tactile signage or floor surface information help you? Y N NA

Are there any other problems/observations or solutions you can Details

think of?

Social Communication Difficulties

Would you be able to safely leave the premises in the event of an
Y N NA
emergency?
Would you like someone to help you evacuate the building? Y N NA

Are you able to manage fire evacuation practice sessions? Y N NA

Could you find your way out of the building if your normal route
Y N NA
was not longer available?
Would you be anxious evacuating the building if you were in a
Y N NA
crowd of other people?
Would you be happy to leave the building after the majority of
Y N NA
other people had left?
Would you be happy to wait in a safe refuge? Y N NA

Are there any other problems/observations or solutions you can Details

think of?
 General Information
Do you understand the emergency evacuation plan that operates
Y N NA
in school?
Do you understand the written escape instructions? Y N NA

Do you need a written copy of your emergency evacuation plan? Y N NA

Do you know where the emergency exits are? Y N NA

Are the emergency exit signs where you can see them? Y N NA

Would you know what to do if you discovered a fire? Y N NA

Are you ever on the premises after school has finished? Y N NA

Do you ever work in a room on your own? Y N NA

Are there any other problems/observations or solutions you can Details

think of?

Assessment carried out with:

Date:

Additional information: