Individual Evacuation Plan
Download a blank fillable Individual Evacuation Plan in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Individual Evacuation Plan with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2South Bend Community School Corporation
Special Education Services
Individual Evacuation Plan
Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________
School: ________________________________ Grade: ________ Age: ________ IEP Date: ________________
The evacuation Plan is to be building specific. If the student moves to a different school, the Evacuation Plan must be
revised to reflect the new placement.
A copy of the Individual Evacuation Plan is to be confidentially posted with classroom fire and storm drill information.
Individual responsible for notifying, Emergency Response Personnel about student(s) with Individual
Evacuation Plan(s) and location of student: ______________________________________________.
It is mandatory that these plans be practiced and documented once a month, or as directed for General Education
students.
Diagnosis(es):
Medical Equipment:
_______________________________________
____________________________________________
_______________________________________
____________________________________________
_______________________________________
____________________________________________
_______________________________________
____________________________________________
Persons responsible for student evacuation: Primary: _________________________________________________________
Alternate 1: ___________________________________
Alternate 2: ________________________________________
Equipment required to accompany student during evacuation: ____________________________________________________
_____________________________________________________________________________________
Person responsible for gathering and transporting equipment:___________________________________________
Fire Evacuation Plan
Procedure for evacuation
Evacuation Out of Building Specific training and/or practice is required
Method of evacuation if student is not able to walk or be taken out in his/her own wheelchair OR student is
not located on ground floor:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Location of Evacuation Exits (use exit as posted in each classroom):
a. ___________________________________________________________________________________
b. ___________________________________________________________________________________
Location of designated waiting area outside of building: _________________________________________
_____________________________________________________________________________________
8/18/12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business