FACILITY EVACUATION ASSESSMENT
FACILITY/DEPARTMENTAL INFORMATION
Verbal Designation Of Assessed Location:
Current Use:
Entry To Location Controlled:  Yes  No  Not Needed
False Egress Locations (Not-An-Exit) Clearly Identified:  Yes  No  N/A
Evacuation Routes Marked:
 Yes  No
Facility Diagrams Posted:
Evacuation Lighting:
 Yes  No
Evacuation Signage Available:
 Yes  No
 Yes  No
RELATED OPERATING PROCEDURES REVIEWED
Hazard Communication
Lock Out Tag Out
Welding Safety
Evacuation Plan




Respiratory Protection
Job Hazard Analysis
Accident Investigation
Emergency Action Plan







Electrical Safety
Process Safety
Fire Prevention

PRINICIPLE FACILITY DESIGN CRITERIA
Source: NFPA
FACILITY DESIGN ALTERNATIVES SHOULD INCLUDE ANY ONE OR ALL
1. Can occupants evacuate in a expeditious manner if needed?
Yes
No
2. Are means available for defending the occupants in place?
Yes
No
3. Are means available to provide an effective area of refuge?
Yes
No
EVACUATION ASSESSMENT CHECKLIST
GENERAL REQUIREMENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Is the location provided with sufficient exits to permit prompt escape?
Has the overall design of the assessed location been considered?
Have above-ground levels been assessed for escape ladders/stairs etc.?
Have all dead-end spaces and routes leading to them been identified?
Have all egress routes been cleared of dead-end spaces/trap conditions?
Have all egress routes leading to dead-end spaces been clearly marked?
Are there at least two exits from every area?
Do exits lead to external areas where occupants could become trapped?
Are all exits clearly marked?
Are all exits unobstructed?
Is emergency lighting available?
Is emergency lighting adequate for the design/construction of the area?
Is emergency lighting tested on a regular basis?
Have all dead-end spaces and routes leading to them been identified?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Are exit components constructed as a permanent part of the building?
Are doors designed to be of the self closing type?
Are doors equipped with emergency push bars or other approved types?
Are provisions in place to allow egress of employees with disabilities?
Are exits so arranged as to maximize egress efficiency?
Do all exit doors swing freely and are they free of blockages?
Do all exits swing in primary direction of escape?
Can snow, leaves, water, or other materials accumulate on the outside?
Can second story exit routes withstand the combined weight of evacuees?
1.
2.
3.
4.
Are exits marked by readily visible signage?
Are access ways to exits marked by readily visible signage?
Are doors, passages, or stairways that are not exits marked “Not an Exit”?
Where “Not an Exit” is NOT USED is the actual identity of location marked (closets, etc.)?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
MEANS OF EGRESS - GENERAL
EXIT MARKINGS - GENERAL
PAGE 1 OF 4
EXIT MARKINGS - GENERAL
(continued)
5.
6.
7.
8.
9.
Are exit signs distinctive in color and provide contrast with other signs?
Are exit signs positioned within line of site of egress routes?
Are exit signs accompanied by an arrow indicating the direction of travel (except over doors)?
Where reduction of lighting is permitted are exit signs illuminated?
Do all exit signs contain lettering size not less that 6” high and .75” wide?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Have evacuation assessment results been incorporated into the EAP?
Has employee emergency action plan training been accomplished?
Have emergency escape routes been determined?
Have emergency escape route procedures been developed?
Have rescue and emergency medical duties been determined/developed?
Has the preferred means of reporting emergencies been developed?
Have EAP point of contacts been established?
Has the adequacy of alarm systems been determined?
Have critical plant operations emergency procedures been established?
Have critical plant operations shut down procedures been established?
Are employee evacuation procedures for critical plant operations in place?
1.
2.
3.
4.
5.
6.
7.
8.
Has an emergency relocation point been established?
Is access to the emergency relocation point unobstructed once outside?
Is the route to the emergency relocation point free of additional hazards?
Have all employees been notified and trained concerning the ERP?
Have ERP arrival procedures been established to provide guidance to employees?
Do all employees understand that they cannot leave the area until accounted for?
Do all employees understand the risks to responders if they are not accounted for?
Has an alternate Emergency Relocation Point been established?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
EMERGENCY ACTION PLAN (EAP)
EMERGENCY RELOCATION POINT (ERP)
EVACUATION NOTIFICATION
1.
2.
3.
4.
5.
XX
Has authority to order evacuation been clearly established?
Have the conditions and criteria to order an evacuation been clearly defined?
Have areas covered by the order to evacuate been clearly defined?
Have standardized evacuation alarm and or signals been established?
Are audible alarm signal tones capable of being heard above ambient noise levels?
HAZARD
AREA ASSESSMENT
RECOMMENDED CORRECTIVE ACTION
Area Entry Restricted
Area Egress Restricted
Evacuation Distance
Obstructed Evacuation Route
Multi-level Considerations
Entrapment (Evacuation)
Fall Hazards (Evacuation)
High Noise Levels (Warning)
Chemical Hazards (Fire)
Chemical Hazards (Reactive)
Chemical Hazards (Vapors)
Electrical Fire Hazards
Toxic Process Material
Oxygen Displacement Area
Oxygen Deficient Area
Oxygen Enrichment Area
Flammable Gases or Vapors
Toxic Gases or Vapors
Airborne Combustible Dusts
Less than 19.5%
More than 23.5%
More than 10% LEL
More than PEL
Meets or Exceeds LFL
RESPONSIBILITY
PAGE 2 OF 4
DIAGRAM OF EVACUATION ROUTE (Indicate Exits)
Instructions: Indicate the anticipated route evacuees should take to reach the Emergency Relocation
Point. Use attachments as required.
 YES  NO
REMARKS/RECOMMENDATIONS
FURTHER DETAILED ON ATTACHMENT(S)
Computer File Name:
CERTIFICATION
I certify that I have conducted a facility emergency evacuation assessment of the location designated
above. To the best of my knowledge, I believe the information contained herein to be true and accurate
as of the time of the assessment.
NAME:
TITLE:
SIGNATURE:
DATE:
TIME:
 AM  PM
 YES  NO
ASSESSMENT FORM RETENTION INFORMATION
FURTHER DETAILED ON ATTACHMENT(S)
PERMANENT RETENTION FILE:
FILE LOCATION:
DATE FILED:
FILED BY:
ATTACHMENT(S) INCLUDED:  YES  NO
TIME:
 AM  PM
PAGE 3 OF 4
CORRECTIVE ACTIONS
Corrective Action:
Responsible Person/Phone:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Corrective Action:
Responsible Person/Phone:
Date:
Estimated Completion Date:
Notes:
 Completed
Date:
Additional Comments/Requirements:
REVIEWERS ACTIONS
 All Actions Completed
Date:
Reviewer’s Name:
Diagrams/Drawings Attached
 Yes  No
Phone:
Signature:
Continued On Attachment
Recommend Further Review
 Yes  No
 Yes  No
PAGE 4 OF 4