Version 2.0
Personal Emergency Evacuation Plan (PEEP)
1. Occupants Name:
Phone:
2. Email:
3. Location:
Campus: Select
Building number:
Floor:
Room Number:
4. Is an Assistance Animal involved?
 Yes
 No
5. Are you trained in the emergency response evacuation procedures?
 Yes
 No
6. Preferred method for receiving updates to the emergency response procedures:
(Please state, e.g. text, email, Braille, voice etc)
7. Type of assistance required. Please list procedures necessary for assistance:
8. Equipment required for evacuation:
9. Egress procedure (provide step by step details):
10. Designated assistants and contact details. Please list name, phone, mobile, email:
11. Are your designated assistants trained in the emergency response and evacuation
procedures?
 Yes
 No
Personal Emergency Evacuation Plan (PEEP) v2.0
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12. Are your designated assistants trained in the evacuation equipment?
 Yes
 No
13. Diagram attached of preferred route and alternate, if available, for assisted evacuation:
 Yes
 No
14. Any additional comments:
Issue Date:
Review date:
Occupant approved:
Date:
Building Warden sited:
Date:
Submit to [email protected]
Reference: Australian Standard AS3745 2010 – Planning for emergencies in facilities
Emergency Management website:
http://www.csu.edu.au/division/facilitiesm/emergency-management
For further information and to submit this form:
Ken Simpson
Manager, Work Health & Safety (Facilities) | Division of Facilities Management
Tel: 02 6933 4321
Mob: 0439 425 482
Email: [email protected]
Personal Emergency Evacuation Plan (PEEP) v2.0
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