School: ___________________________
Date:______________
Demographics
Number of students
______________
Number of staff
___________________
Number of students
with mobility difficulties _________________
Number of staff with
mobility difficulties ___________________
Number of wheelchairs
_________ Is this sufficient? ___ yes ___ no
Physical
Plant
School has floor plans
with clearly marked exits and utility shut-offs posted throughout the building ___ yes ___ no
School has an area map
with safe evacuation zone shown ___ yes ___ no
There is limited
access to the school building ___ yes ___ no
Which doors are open
during the school day? ________________________________
Swipe cards are used ___ yes ___ no
Crisis
Team (CT)
Staff Position | Name | Contact
Numbers Cell/Radio
phone |
Principal | _____________________ | _____________________ |
Assistant Principal | _____________________ | _____________________ |
Guidance Counselor(s) | _____________________ | _____________________ |
Psychologist | _____________________ | _____________________ |
Nurse | _____________________ | _____________________ |
Office Staff | _____________________ | _____________________ |
Custodian | _____________________ | _____________________ |
Extended Day Director | _____________________ | _____________________ |
Others | _____________________ | _____________________ |
_____________________ | _____________________ |
CT contact numbers are
pre-programmed for all members ___ yes ___
no
CT has a regular
meeting time ___ yes ___ no When is it?
____________
Crisis Team meeting
place (Command Post)
In the school
_____________________
Away from the building
___________________
School has prepared an
emergency kit (s) ___ yes ___ no
___ Flash
lights
___ Radio
___ Cell
phone/Radio phone
___ Parent
contact numbers
___ Other
Designated responsibilities in the event of Emergency:
Responsibility | Person |
___ Emergency
kit(s) | _________________________________ |
___ Attendance
(for students and staff) | _________________________________ |
___ First
aid | _________________________________ |
___ Emergency
medications | _________________________________ |
___ Parent
notification | _________________________________ |
___ Media | _________________________________ |
___ HVAC
and utilities shut-off | _________________________________ |
Annual crisis simulation (tabletop) exercise: Date:
_____________________
Emergency
Medical Response Team (EMRT)
Person | Contact
Numbers (cell/radio phone/walkie-talkie) |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
Nurses
___ Has
sub folder which includes Emergency Plan
___ Logs
absences and illness daily
___ Has
portable first aid kit(s)
___ Has
portable emergency medical kit(s) with emergency medical cards
___ Has
cell phone/radio phone number (s)__________________________
Staff
All staff are identified
in some way ___ yes ___ no How?
________________
All visitors are
identified in some way ___
yes ___ no How? ________________
There is a policy
regarding unidentified adults in the building ___ yes ___ no
Staff are informed of
Emergency Plan ___ yes ___ no Date: __________________________
Staff know
evacuation/relocation protocol ___ yes ___
no
Know route(s) to
relocation sites ___ yes ___ no
(See
Evacuation/Relocation plan for specific information)
Have practiced ___ yes ___ no Date: __________________________
Staff know
shelter-in-place protocol ___ yes ___ no
Know designated area
for particular grade level/class ___ yes ___ no
(See shelter-in-place
plan for specific information)
Have practiced ___ yes ___ no
Date: _____________________________
Staff know lockdown
protocol ___ yes ___ no
Staff in open areas
knows to which lockable rooms to go ___ yes ___
no
(See Lockdown plan for
specific information)
Have practiced ___ yes ___ no Date: __________________________
All classroom teachers have accessible emergency folders ___ yes ___ no, which include:
___ Emergency
Response Manual
___ School
evacuation/relocation plan
___ Class
list with multiple contact numbers for all families
___ Emergency
medical forms
Classroom teachers have a kit to bring to relocation site with
activities for students ___ yes
___ no
Each classroom has room parents ___ yes ___ no
Each classroom has class phone trees which includes cell
phone numbers ___ yes ___ no
Evacuation/Relocation Plan
Relocation site(s) is (are):
Relocation site | Grade
Levels |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
Staff are informed of
walking routes to each site ___ yes ___
no
___ Attach walking routes
to each relocation site
Responsibility for "sweeping" areas of the building:
Person | Area |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
________________________ | __________________________________ |
Responsibilities at each site:
Responsibility | Person | Site |
Emergency
Kit | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
Attendance | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
First
Aid (EMRT) | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
Emergency
Medications | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
Communication | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
Parent
contact | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ | _________________________________ |
Distractions/Snacks | _________________________________ | _________________________________ |
_________________________________ | _________________________________ | _________________________________ | _________________________________ |
Communication between
sites, with town EMTs, and central office:
Number of radio phones_____________
Grouped? ______________
Number of cell phones
_________________
Person responsible
_______________________________
System in place for
communicating relocation to parents, e.g. voicemail message ___ yes ___ no
Plan has been
communicated to parents ___ yes
___ no Date: __________________________
Relocation drill
practiced with ___ staff or ___ staff and students:
Date: __________________________
Shelter-in-Place
Plan: Recommended
shelter-in-place location:_________
Staff have been
informed of shelter-in-place protocol ___ yes ___
no Date: __________________________
Staff know specific
areas to which to bring students ___ yes ___ no
___ Attach map of
shelter-in-place location with designated areas
CT and EMRT Responsibilities during Shelter-in-Place:
Responsibility | Person |
Attendance | _________________________________ |
Emergency
Kit | _________________________________ |
First
Aid | _________________________________ |
Emergency
Medical Kit | _________________________________ |
HVAC
and Utility Shut-Off | _________________________________ |
Parent
Communication | _________________________________ |
Communication with town and central office | _________________________________ |
Other: | _________________________________ |
Plan has been
communicated to parents ___
yes ___ no Date:
____________________
Shelter-in-place drill
practiced ___ staff only ___ staff and students: Date:
____________________
Lockdown
Plan
Staff have been
informed of lockdown protocol ___ yes ___
no Date:
____________________
Staff in open areas
know of nearby lockable rooms ___ yes ___
no
___ Attach plan or fill in
below:
Open Areas | Rooms
to go to |
| |
| |
| |
Plan has been
communicated to parents ___ yes
___ no Date:
____________________
Lock-down drill
practiced with ___ staff only ___ staff and students: Date:
____________________
After-School
and Extended Day Programs
The people responsible for making emergency response
decisions in the after-school programs in your building are:
___________________________
___________________________
___________________________
___________________________
The particular needs of after-school programs are addressed
in your school's Emergency Plan
___ yes ___ no
The emergency protocols for your school, the evacuation/relocation,
shelter-in-place, and lockdown plans, have been discussed with the Extended Day
director and other administrators of after-school programs ___ yes ___ no
The Extended Day director has a copy of the School Emergency
Response Manual ___ yes ___ no
The Extended Day program has a complete emergency response kit
___ yes ___ no
Extended Day staff are trained in first aid and CPR ___ yes ___ no
Staff in the Extended Day programs and other after-school
programs have cell phones or walkie-talkies to communicate with each other in
case of emergency ___ yes ___ no
The administrators of after-school programs know whom to
contact in the town in case of a major emergency ___ yes ___ no
The Extended Day and other after-school
programs have a plan for communicating with all parents in case of a major
emergency ___ yes ___ no
All after-school staff have
emergency contact numbers for all their students ___ yes ___ no
Communication
with Town Emergency Management Team and Central Office
Met with town safety officer
___ yes ___ no Date:
____________________
Radio phones and cell
phones are charged ___ yes ___ no
Radio phones are
preprogrammed and grouped with town EMT ___ yes ___ no
Radio phones are
grouped with central office ___ yes ___ no
Cell phones are
preprogrammed to contact central office ___ yes ___ no
A copy of this summary
has been sent to the central office ___ yes ___ no
Date:
____________________
Issues
that still need to be addressed:
Signature of Principal __________________________
Date:
____________________
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