HEALTH & SAFETY
MULTI STOREY BUILDING 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 REQUESTED
Fire
Security Control Room (x46666)
Ambulance
University Asset Services (Maintenance) (x46000)
Police
Emergency Management Coordinator
4.
AREA AFFECTED
5.
WARDEN REPORTS
FLOOR
NOTIFIED CLEAR
FLOOR
NOTIFIED CLEAR
Basement 3
Clear
Time:
4
Clear
Time:
Basement 2
Clear
Time:
5
Clear
Time:
Basement 1
Clear
Time:
6
Clear
Time:
Ground
Clear
Time:
7
Clear
Time:
1
Clear
Time:
8
Clear
Time:
2
Clear
Time:
9
Clear
Time:
3
Clear
Time:
10
Clear
Time:
All EXITS guarded to prevent re-entry
safety.unimelb.edu.au
Number Evacuated:
HEALTH & SAFETY: MULTI STOREY BUILDING EVACUATION CHECKLIST 1 of 2
Date: May 2016 Version: 1.0 Authorised by: Associate Director, Health & Safety Next Review: May 2019
© The University of Melbourne – Uncontrolled when printed.
6.
CHIEF WARDEN REPORT
Problems/Concerns /Matters to be followed up
7.
ADDITIONAL NOTES
safety.unimelb.edu.au
HEALTH & SAFETY: MULTI STOREY BUILDING EVACUATION CHECKLIST 2 of 2
Date: May 2016 Version: 1.0 Authorised by: Associate Director, Health & Safety Next Review: May 2019
© The University of Melbourne – Uncontrolled when printed.