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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.

1. INCIDENT DETAILS Building Name       Time      

Building Number       Date      

2. 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

3. ASSISTANCE REQUESTEDFire Security Control Room (x46666)

Ambulance University Asset Services (Maintenance) (x46000)

Police Emergency Management Coordinator

4. AREA AFFECTED     

5. 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:            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.

AREA AREA DESCRIPTION (EG FLOOR) NOTIFIED CLEAR COMMENTS

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:

6. CHIEF WARDEN REPORTProblems/Concerns/Matters to be followed up

7. ADDITIONAL NOTES     

safety.unimelb.edu.au HEALTH & SAFETY: BUILDING EVACUATION CHECKLIST 2 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.