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Using This Template: Example
Using This Template: Example
The following template can be used to help your organization develop a written Emergency Action Plan. This
template cannot be used as is – you must customize the template to meet the needs of your organization. We
have made this template easier for you to customize by adding visual prompts that identify some areas where
your input is needed. These are identified by yellow highlighted, red text in the template. You may also change
any of the text in the template to meet your organization’s needs – for example, department names, job titles
and listed responsibilities and procedures.
Example:
<COMPANY NAME>
Emergency Action Plan
becomes
XYZ Company
Emergency Action Plan
To remove the colored highlighting from your text, left click and drag your mouse over the yellow text and click
on the highlighter button from the Font menu. To change the font color to black, select the text and click on the
font color button.
To aid you in understanding the need to customize your program, several “Check Your Understanding” text
boxes are also included throughout the template. After reading the information in the text box and adding the
required information into the template, you may simply right click on the cross arrow box and select “cut.”
Disclaimer. This sample safety program template cannot be used as is. You must customize the template to meet the needs of your
organization. HSSE WORLD does not guarantee that this template is or can be relied on for compliance with any law or regulation,
assurance against preventable losses, or freedom from legal liability. We make no representations or warranties of any kind whatsoever,
either express or implied, in connection with the use of this template. HSSE WORLD will not be liable for your use of the template as
customized by you. All safety programs and policies, including this template and the information you supply to complete it, should be
reviewed by your legal counsel and/or risk management staff.
<COMPANY NAME>
Emergency Action Plan
Check Your Understanding. Almost every type of business is required by the Occupational Safety and Health
Administration (OSHA) to have an Emergency Action Plan 29 CFR 1910.38(a) An Emergency Action Plan is a written
document that guides employers and employees initial actions during workplace emergencies such as fires, hazardous
chemical releases and severe weather. A well-developed Emergency Action Plan and employee training can result in
fewer and less severe injuries and less damage to facilities during emergencies.
Plans should include site-specific information on possible emergency scenarios, evacuation procedures, emergency
reporting mechanisms and alarm systems. For smaller organizations of 10 or less employees an informal plan is
appropriate. For additional information, refer to the Emergency Action Plan document from EMC Insurance
Companies or review OSHA’s Evacuation Plans and Procedures eTool.
Revision History
<Revision 1 – October 2015>
Program Responsibilities
Management. The management of <Company Name> is committed to the safety of its employees, visitors and
contractors. Management supports the efforts of the Program Administrator by pledging financial and leadership
support. Management will regularly communicate with employees about the program.
Program Administrator. The Program Administrator reports directly to upper management and is responsible for this plan.
All evaluations, controls and training are coordinated under the direction of the Program Administrator in collaboration with
management and employees. The Program Administrator will also:
Identify emergency situations that may affect our organization and determine the appropriate course of action
before, during and after those emergencies
Ensure each department or functional area has a copy of the plan
Schedule employee training and ensure new hires are properly trained on the plan
Schedule drills and tabletop exercises
Activate appropriate emergency procedures when necessary
Notify and coordinate response actions with local emergency responders
Periodically review the plan and update as needed
Direct the shutdown of utilities or specific plant processes as necessary
Check your understanding. First responders are specially trained employees who have volunteered to assist in
medical emergencies until community emergency responders arrive.
Area/Floor Coordinators. <Company Name> area/floor coordinators are employees who have volunteered to assist in
communicating the Emergency Action Plan to other employees in their immediate area. Additionally, these employees
will communicate the evacuation status of their area to the Program Administrator during drills and actual incidents.
Area coordinators will also:
Attend Emergency Action Plan training
Assist employees in their area in the safe and orderly evacuation of the building
Assist employees in their area to the proper shelter-in-place locations
Understand the alarm systems and emergency equipment
Review emergency procedures with new employees in their area
Communicate to the Program Administrator where employees in need of assistance are located
Know primary and secondary exit routes
Know the location of hazardous items in their area, such as flammables, radioactive materials, etc.
A list of coordinators can be found in Appendix E.
Managers and Supervisors. Managers and supervisors of <Company Name> will:
Attend Emergency Action Plan training
Ensure employees in their area have received training on the Emergency Action Plan
Maintain an updated list of employees noting those with special assistance needs
Employees. Every <Company Name> employee is responsible for conducting himself/herself in accordance with this plan.
All employees will:
Attend Emergency Action Plan training
Follow all procedures in the plan and all alarms or verbal instructions given during an emergency
Become familiar with evacuation routes, assembly areas and shelter locations
Respond to all emergencies in an orderly manner
Check Your Understanding. Employees with disabilities or special assistant needs should notify their supervisor and
area/floor coordinator of any assistance they require to safely evacuate or move to shelter-in-place locations. This
includes those who are mobility impaired, visually impaired, hearing impaired, temporarily impaired, mentally
impaired and/or those employees who have a health condition which may be aggravated by evacuating down stairs
or through smoke-filled areas. Special procedures and/or assistance may be needed to ensure the affected employees
are notified of the emergency and the need to evacuate or shelter-in-place.
Emergency Reporting
During an emergency, employees who are in a position to safely communicate should call 911 and have another person
call the <Security Operations Center at 555-555-5555>.
Check Your Understanding. Dialing 911 is the most common method for reporting emergencies, but internal numbers
may also be used depending on your situation. Proper emergency numbers should be posted on or near each phone.
Instructions for using any internal intercom systems should also be posted so that emergency announcements can be
made.
Alarms
<Company Name> uses <audible horns, strobes and voice announcements> to communicate emergencies to employees.
See Appendix A for details on all emergency alarms.
Drills. Each <Company Name> location will perform the following drills annually.
Fire drill – March and September
Severe weather drill – April
Lockdown drill – January and July
Drill of choice from emergency plan - October
Prior to each drill, the Program Administrator will identify personnel to assume command of the drill and post-drill
activities. Records of drills will be logged using the form in Appendix D.
After each drill, management and the Program Administrator will evaluate and document the drill results, noting any
particular problems or concerns. They will establish an improvement plan with detailed goals and assign tasks to those
affected with clear, specific deadlines.
Check Your Understanding. Tabletop exercises are group discussions of scenarios in a relaxed, low-stress
environment that provide the opportunity to practice dealing with emergencies. Tabletop exercises should test all
elements of the emergency plan. These exercises are useful in evaluating emergency procedures before an actual
emergency incident occurs. Limit participants initially but consider adding local emergency responders later in the
process.
Tabletop Exercises. The Program Administrator will coordinate tabletop exercises twice a year at each location to test
elements of the Emergency Action Plan. The exercise should be determined based on drill results or other observed
elements needing improvement. If no improvement opportunities are identified, then use a high-hazard scenario.
<Company Name> will use the FEMA tabletop model.
Employee Training
General Training Requirements. All employees will receive training on the following Emergency Action Plan elements
within the first 30 days of employment and annually thereafter:
Emergency reporting procedures
Alarms/notices/announcements
Exits/shelters/assembly locations
Emergency duties and responsibilities
All training will be recorded on the Employee Training Record Form located in Appendix C.
Record Retention
<Company Name> will maintain the Emergency Action Plan training records and emergency drill logs for <number> years.
All Emergency Action Plan records will be kept by the Program Administrator.
Check Your Understanding. There are currently no requirements for Emergency Action Plan report retention. Your
company must determine the time period for record retention.
Appendix A – Employee Emergency Handbook
<COMPANY NAME>
<Date of Plan>
Emergency Numbers
Fire or Police ____________________________________ 911
Emergency Personnel
Program Administrator:
Area/Floor Coordinators:
All personnel are expected to know at least two evacuation routes and their designated assembly area.
<Insert evacuation route/assembly area diagram here>
Fire
1. Immediately and calmly evacuate the building. Go to the nearest exit. Do not use the elevators. If the fire
alarm is not activated, pull the fire alarm on the way out of the building. If the fire alarm doesn’t sound or if
a pull station is not nearby, communicate that everyone should begin to calmly evacuate the building.
2. Call 911 when safe and provide the dispatcher with the following information:
a) Address of the facility
b) Your name
c) If there are injuries, the size of the fire and other pertinent information
3. Go to your designated assembly area as indicated on the evacuation route/areas of assembly map.
4. Area/floor coordinators will communicate to the emergency team the evacuation status of the floor or area.
5. Stay where you are. Do not leave your assembly area until your supervisor or area/floor coordinator directs
you to do so.
<A tone will sound three times and an automated announcement will be made – “May I have your attention
please. May I have your attention please. A tornado warning has been issued for this area. A tornado
warning has been issued for this area. Please seek immediate shelter in your designated shelter area.”>
Earthquake
1. In the event of an earthquake stay calm and seek shelter under sturdy furniture, in doorways or outside.
2. Keep away from overhead fixtures, windows, filing cabinets and electrical power sources.
3. Evacuate the building as soon as possible after the earthquake.
4. Go to your designated assembly area as indicated on the evacuation route/areas of assembly map.
5. Area/floor coordinators will communicate the evacuation status of the floor or area to the emergency team.
6. Stay where you are. Do not leave your assembly area until your supervisor or area/floor coordinator
instructs you to do so.
Lockdown
If you are in the immediate vicinity of active violence, evacuate or hide out.
Attempt to evacuate the building if there is a safe, accessible escape path.
If evacuation is not possible, find a place to hide where the perpetrator is less likely to see or find you.
Once out of the building or hidden, call 911. Have another person call <555-555-5555> to alert the
building security.
Evacuate
If you decide to evacuate, do so whether others agree to follow or not
Leave belongings behind
Alert others to the danger as you evacuate
Follow the instructions of any police officers
Do not attempt to move wounded people
Hide Out
Get out of sight
Seek shelter in offices or other areas with doors
Lock the door if possible, or blockade the door with furniture
Silence your cell phone and turn off any other noise sources
Hide behind large items
Remain quiet until resolution message is announced
Lockdown Announcement
Upon notification of an active violence event in the facilities, security will make the following building-wide
announcement:
<“Lockdown. Lockdown. There is an active threat in the building. Seek safety immediately.” (Repeat)>
Upon resolution of the threat, security will make the following building-wide announcement:
<“Attention. Attention. The emergency in the building has been resolved. Return to your normal activities if
possible and contact your supervisor for further information.”>
Large Spills
1. Immediately notify the Program Administrator and call 911 if necessary.
2. Contain the spill with the equipment in the spill containment containers.
3. Secure the area to prevent others from entering and alert all site employees.
4. Do not attempt to clean up the spill.
5. Attend to injured employees.
6. Contact <spill clean-up company> at <555-555-5555> to perform a large chemical spill cleanup.
7. Evacuate building if necessary.
Processes or operations that must be shut down before total building evacuation are listed below. Emergency
shutdown procedures are documented at the machine and available in the Program Administrator’s office.
Employees in charge of these critical functions and at least two backups will be trained on emergency shutdown
procedures. These employees have received training in recognizing when to abandon shutdown and evacuate.
Comments:
Appendix C – Training Record For The Emergency Action Plan
The undersigned conducted training in accordance with <Organization’s> Emergency Action Plan.
Fire/Evacuation Drills: Practice using secondary evacuation routes once per year.
Date Date Weather # Of Evacuation Comments
Scheduled Conducted Conditions Participants Time