Emergency Management

health & safetyBUILDING EVACUATION CHECKLIST

This form is to be used by the Chief Warden as an evacuation checklist during an emergency evacuation. As the Wardens report in to you, record which areas have been cleared and anything they have to report. This form will help you brief the Emergency Services or the Emergency Management Coordinator when they arrive on scene.

Incident Details

Building Name

Time

Building Number

Date

Emergency

Fire

|_|

Armed or Aggressive Intruder

|_|

Gas Emission

|_|

Building Damage

|_|

Explosion

|_|

Medical Emergency

|_|

Bomb Threat

|_|

Flooding

|_|

Substance Threat

|_|

Blackout Loss of Power

|_|

Chemical Spill

|_|

Other

|_|

Assistance Requested

Fire

|_|

Security Control Room (x46666)

|_|

Ambulance

|_|

University Asset Services (Maintenance) (x46000)

|_|

Police

|_|

Emergency Management Coordinator

|_|

Area Affected

Warden Reports

Area

AREA DESCRIPTION (EG FLOOR)

Notified Clear

Comments

A

Clear |_| Time:

B

Clear |_| Time:

C

Clear |_| Time:

D

Clear |_| Time:

E

Clear |_| Time:

F

Clear |_| Time:

G

Clear |_| Time:

H

Clear |_| Time:

I

Clear |_| Time:

J

Clear |_| Time:

K

Clear |_| Time:

L

Clear |_| Time:

M

Clear |_| Time:

N

Clear |_| Time:

All EXITS guarded to prevent re-entry

|_|

Number Evacuated:

CHIEF WARDEN report

Problems/Concerns/Matters to be followed up

ADDITIONAL NOTES

safety.unimelb.edu.au Health & safety: BUILDING EVACUATION CHECKLIST 1 of 2

Date: August 2017 Version: 1.0 Authorised by: Associate Director, Health & Safety Next Review: August 2022

The University of Melbourne Uncontrolled when printed.