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Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix F.  Annual School Emergency Preparedness Summary Form

Make a copy of this blank form, as it will be needed for future years.

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 PositionNameContact 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:

 
   ResponsibilityPerson
___ 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)

 
   PersonContact 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 siteGrade 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:

 
   PersonArea
________________________ __________________________________
________________________ __________________________________
________________________ __________________________________
________________________ __________________________________
________________________ __________________________________

Responsibilities at each site:

 
   ResponsibilityPersonSite
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:

 
   ResponsibilityPerson
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 AreasRooms 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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AHRQ Publication No. 09-0013
Current as of January 2009

 

The information on this page is archived and provided for reference purposes only.

 

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