EMERGENCY EVACUATION SAFETY PLAN FOR WORK/DAY SUPPORTS

The Emergency Evacuation Safety Plan form has instructions for completing the different elements of the plan. For expanded guidance on each element of the plan, please refer to the Emergency Evacuation Safety Plan Guidelines Handbook.

GENERAL INFORMATION

Date of Completion:		
Agency:		
Day Support Site and Address:		
	
Number of Individuals Served At Site:		Typical Daily Census		

Type of Day Support (check the appropriate box):

Sheltered Workshop Setting		Yes	

Community Based Day Supports		Yes	

Employment Supports		Yes	

Type of Building (check the appropriate box, give the number of floors in the building, and identify the specific floors where supports are provided):

Agency support occupies entire building (freestanding)		Yes		# Floors	

Multiple use building		Yes		# Floors	Support located on Floors		

Other (please describe):  

ENVIRONMENTAL

Fire Safety Equipment (check the box at right to indicate the types of fire safety equipment present at the site):

Smoke Detection System

Interconnected smoke detectors									
Battery operated smoke detectors									
Alarm system hard-wired to Fire Department or central monitoring station				

Other Safety Equipment

Automatic door closers										
Fire suppression (sprinkler) system									
Emergency battery-operated lighting									
Fire extinguishers											

Other (describe):  

 	

SITE FLOOR PLAN

Using page 7 in this document, create a floor plan of each floor of the site accessed by individuals, with each egress clearly marked using the following chart of egress types.  Attach additional pages as needed.

EGRESS TYPES	
a.	Interior Stairs
b.	Elevator
c.	Door to Exterior Stairs to Grade
d.	Door directly to Grade
	e.	Handicap Accessible Ramp
f.	Basement Interior Stairs
g.	Basement Stairs to Grade (Bulkhead Type)
h.	Door to common hallway to egress(s)
i.	Other (describe)	

Individual Abilities And Safety Strategies

This section is a summary description of individual characteristics that affect the ability to evacuate the day site safely within a reasonable period of time during an emergency.  This does not replace the need for a thorough assessment of individual skills at the time of the ISP, but rather is taken from those assessments.  Refer to the Emergency Evacuation Safety Plan Guidelines Handbook for information helpful in completing this section.

1.		What is the total number of individuals that require assistance to evacuate?		

2.	Does the level of ability of any individual prevent or limit their ability to evacuate independently?

	Yes		No	If Yes, Number of Individuals		

3.	Does any individual have mobility issues that would prevent or limit their ability to evacuate independently?

	Yes		No	If Yes, Number of Individuals		

4.	Does any individual have health related issues that would prevent or limit their ability to evacuate independently?

	Yes		No	If Yes, Number of Individuals		

5.	Does any individual have social or behavioral needs that prevent or limit their ability to evacuate independently?

	Yes		No	If Yes, Number of Individuals		

6.	Does any individual need adaptive devices or equipment to ensure safe and timely evacuation?

	Yes		No	If Yes, Number of Individuals		

GROUP INTERACTIONS

Are there any interactions between individuals or any group dynamics that could affect timely evacuation, either positive or negative?

		Yes		No

If yes, describe:  

EVACUATION PLAN

The evacuation plan incorporates components discussed previously, including individual abilities, group interactions and dynamics, staff responsibilities, adaptive equipment, egresses. 

Minimum # of staff to individuals:		

Using a bullet format as needed, answer each of the following questions, adding additional pages as needed:

1.	Describe the sequence for ensuring the safe evacuation of all individuals from the site and each staff’s or supporter’s responsibilities.  Include the specific accommodations and assistance needed by specific individuals, such as staff role with adaptive devices.  
	
2.	State the amount of time needed to safely evacuate all individuals.
	
3.	Identify the primary escape route.
	
4.	Identify the secondary escape route.
	
5.	Identify the escape route(s) for individuals using wheelchairs.

6.	
Identify the location of the central meeting place.

FIRE DRILLS

DDS Regulations 115 CMR 7.08 requires that the day support conduct two fire drills per year.  Refer to the Emergency Evacuation Safety Plan Guidelines Handbook for additional information.

Complete the following:

Number of annual fire drills: 		

Do the proposed fire drills differ from the number and schedule required in DDS Regulation 115 CMR 7.08 as described above?		Yes		No	

If the answer is yes, describe the proposed schedule and why it differs from this regulation:  

 	

METHODS TO NOTIFY POLICE, FIRE, EMERGENCY PERSONNEL, FAMILIES, DMR

Are all staff aware of procedures for notifying police, fire, emergency personnel, and relevant “on call” staff?		Yes		No	
Who will make the call?		
To whom will the call be made?		
When and where will the call be made?		

What is the protocol for notifying “on call” staff of the provider, families/guardians, and the DMR area office?

IMMEDIATE RELOCATION

What is the plan for providing immediate shelter during the emergency:  

OTHER COMMENTS (Optional)

Please use this section to include any other relevant information not previously addressed.

Site Floor Plan

Egress Types

a.	Interior Stairs	d. Door Directly to Grade	g. Basement Stairs to Grade (Bulkhead Type)
b.	Elevator	e. Handicap Accessible Ramp	h. Door to Common Hallway to Egress (s)
c.	Door to Exterior Stairs to Grade	f. Basement Interior Stairs	i. Other (describe)

Address: 		

Floor # 		

PROVIDER ASSURANCE FORM
	
       I hereby certify under the pains and penalties of perjury that the home or work/day support

located at                                                      with a capacity of        individuals, and 

operated by                                                 meets or exceeds, or with respect to a new                                 (name of provider)

support, agree to meet or exceed the requirements for assurances of safety as listed below and in accordance with the regulations of the Department of Developmental Services (115 CMR 7.08).

1.	The written Emergency Evacuation Safety Plan includes all the applicable components required in 115 CMR 7.08(3); or the current disaster and evacuation plan will remain in effect.

2.	The Emergency Evacuation Safety Plan is designed for the safety of individuals requiring evacuation in an emergency, is implemented, and is periodically evaluated for effectiveness.

3.	All required fire safety equipment as referenced in the safety plan is functional (i.e., smoke detectors, alarms, adaptive equipment, sprinklers, or emergency back-up systems, if applicable).

4.	The following documentation, as applicable, is available for review:

	a.  Fire Drill log;

	b.  Emergency Evacuation Safety Plan;

	c.  Documentation that each staff person/home provider has been trained in implementation of the Emergency Evacuation Safety Plan.
	
Provider:

Signed                                                                 Date:                                     

Print Name & Title:

DDS Area Director:  I have reviewed and approved the Emergency Evacuation Safety Plan as submitted.

Signed                                                                 Date:                                     

Print Name & Title: