Appendix 2: PEEP Questionnaire and Template

Emergency Egress Questionnaire

1. Why you should fill in the form

As your employer, , has a legal responsibility to protect you from fire risks and ensure your health and safety at work. To do this properly we need to know:

  • if you require information about our emergency egress procedures; and
  • if you need assistance during an emergency.

It shouldn't take you more than a few minutes to complete the form.

2. What will happen when you have completed the form

We will be able to provide you with information you need about the emergency egress procedures in the building(s) in which you work.

If you need assistance, we will be able to work out a Personal Emergency Egress Plan for you. To do this, we will discuss the best ways of getting you out quickly and comfortably. We will involve you, your manager and the person(s) in charge of the building(s) in which you work. But don't worry; we do not see you as the problem; you are not a safety risk. The problem belongs to us and the building in which you work.

Name

Job Title

Department

Brief Description of Duties

Location

1. Where are you based for most of the time?

Please name the building, the floor and the room number.

2. Will your job take you to more than one location in the building in which you are based?

  • Yes / No

3. Will your job take you to different buildings?

  • Yes / No

Awareness of Emergency Egress Procedures

4. Are you aware of the emergency egress procedures that operate in the building(s) in which you work?

  • Yes / No

5. Do you require written emergency egress procedures?

  • Yes / No

5a. Do you require written emergency egress procedures to be supported by ISL interpretation?

  • Yes / No

5b. Do you require emergency egress procedures to be in Braille?

  • Yes / No

5c. Do you require emergency egress procedures to be on tape?

  • Yes / No

5d. Do you require emergency egress procedures to be in large print?

  • Yes / No

6. Are the signs which mark the emergency exits and the routes to the exits clear enough?

  • Yes / No / Don't know

Emergency Alarms

7. Can you hear the fire alarm(s) provided in your place(s) of work?

  • Yes / No / Don't know

8. Could you raise the alarm if you discovered a fire?

  • Yes / No / Don't know

Assistance

9. Do you need assistance to get out of your place of work in an emergency?

  • Yes / No / Don't know

If No, please go to Question 13

10. Is anyone designated to assist you to get out in an emergency?

  • Yes / No / Don't know

If No, please go to Question 12. If Yes, give name(s) and location(s).

11. Is the arrangement with your assistant(s) formal (that is, is the arrangement written into their job description)?

  • Yes / No / Don't know

11a. Are you always in easy contact with those designated to help you?

  • Yes / No / Don't know

12. In an emergency, could you contact the person(s) in charge of evacuating the building(s) in which you work and tell them where you are located?

  • Yes / No / Don't know

Getting Out

13. Can you move quickly in the event of a fire?

  • Yes / No / Don't know

14. Do you find stairs difficult to use?

  • Yes / No / Don't know

15. Are you a wheelchair user?

  • Yes / No / Don't know

Thank you for completing this questionnaire. The information you have given us will help us to meet any needs for information or assistance you may have.

Remember, we do not see you as the problem; you are not a safety risk. The problem belongs to us and the building in which you work.

Please return your completed form to:

Personal Emergency Egress Plan

  • Name:
  • Date:
  • Position:
  • Designated Assistance:
  • Assistance Methods/Techniques:
  • Equipment Provided:

Emergency Evacuation Procedure(s)

(a step-by-step guide, from alarm to safety, of the evacuation procedures from different floors and buildings):

Evacuation Route(s):

(preferably with diagrams)

Back to top