Fillable Individual Evacuation Plan (Page 2 of 2) in pdf

Student Name: __________________________ SBCSC ID#: ______________ STN#: ____________________

School: ________________________________ Grade: ________ Age: ________ IEP Date: ________________

Evacuation to waiting area Inside Building (This is to be used as a last resort. Students should be evacuated outside of

building with few exceptions.)

Emergency equipment to be kept at waiting area or transported with student (e.g. window evacuation sign,

flashlight, medical equipment): ___________________________________________________________________

__________________________________________________________________________________

Location of previously identified waiting areas:

First Floor: _____________________________________________________________________________________

Second Floor: ___________________________________________________________________________________

Additional Floor/Other: ____________________________________________________________________________

Additional Instructions (e.g. wait for evacuation by fire department, etc.): _____________________________________

_______________________________________________________________________________

Storm Evacuation Plan

Procedure for Evacuation to Shelter Area: _______________________________________________________________

_______________________________________________________________________________

Emergency equipment to be kept at or go with the student to shelter area: (blanket, flashlight, water, etc.):

_______________________________________________________________________________

Location of shelter areas for storm evacuation:

Student can follow designated shelter plan

Student requires special considerations (e.g. electrical outlet)

First Floor: _____________________________________________________________________________________

Second Floor: __________________________________________________________________________________

Additional Floor/Other: ____________________________________________________________________________

A copy of the Individual Evacuation Plan to: designated building evacuation administrator, individuals responsible for

evacuation of student, and classroom(s) of student.

Attach a copy of the student's class schedule

Attach a copy of the building floor plan (Available from the school secretary)

A copy of this Evacuation Plan must be attached to the student's IEP, placed in student's cum folder and copies distributed

to staff involved in any and all evacuations.

A copy of this Evacuation Plan must be placed in the school Individual Evacuation Plan folder.

8/18/12

Individual Evacuation Plan Page 2