Form Gsa 3697 - Evacuation Report/survey 2009
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2EVACUATION REPORT/SURVEY
To Be Completed by ALL Wardens and Monitors
Following a partial or full evacuation, the Emergency Coordinators and Floor Wardens and
Monitors are to complete this form. All requested information should be provided. If necessary,
additional sheets are recommended for comments. Floor Wardens/Monitors should forward their
completed report to their HSSO. HSSO’s should review all reports for completeness, consolidate
multiple reports, prepare an overall summary report and keep a copy for their record. The HSSO
should forward all completed reports, along with the summary report, to the Director, Office of
Management Services. All reports are due to the Director, Office of Management Services by
Close of Business the day following the evacuation event.
1a. Date of Evacuation:
1b. Time of Evacuation:
2. Indicate time elapsed (to the nearest minute) from the sounding of the alarm until all employees/visitors
evacuated the area.
3. Number of employees/visitors within your area of responsibility, approximately
4. Was evacuation orderly?
YES
NO
4a. If not, why?
5. Could Fire Alarm be heard?
YES
NO
5a. If no, indicate the locations at which they couldn't be heard
6. Did Strobe Lights operate?
YES
NO
6a. If no, indicate the locations at which they did not operate
7. If the public address system was used, was the evacuation announcement
YES
NO
broadcasted in a loud, clear manner?
7a. If no, indicate locations and faults.
8. Was an outside all clear announcement given?
YES
NO
9. What hinderances to rapid evacuation, if any, were encountered?
10. Did the mobility evacuation personnel assigned to special duties carry out
YES
NO
their assignments?
10a. If no, explain:
GENERAL SERVICES ADMINISTRATION
GSA 3697 (10/2009)
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Parent category: Financial