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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
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Circular Exhibit 03-01-B


EMERGENCY PROCEDURE REVIEW FORM

This form is to be used by the Building Evacuation Coordinator following the occurrence of an emergency evacuation or a building lockdown procedure.  The Building Evacuation Coordinator will determine the method of distribution and to whom this review form will be distributed, whether by e-mail to all Headquarters employees or to selective employees, or randomly.  Information from this form will be used to assess the effectiveness of the Headquarters Emergency, Security, and Safety Guidance.

PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE RECENT EMERGENCY:

Your Name:

__________________________________________________________________________________
Organization:

__________________________________________________________________________________
Room Number:

__________________________________________________________________________________
Telephone Number:

__________________________________________________________________________________

Are you a member of the Emergency Organization Team? (If YES, give assignment)

Describe the alarm sound(s) you heard and their location(s).

Did you evacuate the building? (If NO, please explain circumstances)

Did you experience any problems during the evacuation? (If YES, please explain)

We are interested in feedback about evacuations. Please provide any suggestions you may have for improving the Evacuation Plan on a separate sheet of paper.

Please complete and return this form to the person who e-mailed it to you, or print out the form, complete it, and provide it to your Floor Coordinator.


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