1. Personal Emergency Evacuation Plan Form
Name of Care Centre
This Personal Emergency Evacuation PlanwasPrepared For
Name of Resident
The content of this document is confidential
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 1 of 7

2. Personal Emergency Evacuation Plan Form
This Personal Emergency Evacuation Plan (PEEP) has been prepared by PHOENIX SAFETY
TRAINING SERVICES; its purpose is to identify the individual needs of a resident with regard to their
safe evacuation in an emergency. The PEEP should be completed ONLY by a COMPETENT PERSON
as defined in the Safety Health and Welfare at Work Act 2005. The PEEP Form is not exhaustive and
where additional requirements are identified they should be entered in “Section D under Other
Information” showing any remedial actions deemed necessary. Each resident should have a PEEP
prepared prior to their arrival or if already a resident within the Care Centre.
The PEEPshould as far as practicable be specific to individual areas in the Care Centre. However if for
example, a number of activities are proposed to take place in adjacent areas from which escape will be
affected using the same emergency provisions then it may be possible to assess the provisions on one
PEEP Form. Hearing impaired residents will normally be able to be assessed on one PEEP Form since the
provisions made for this class of resident are likely to be the same regardless of location.
It is important to distinguish in the PEEP whether the area to be accessed will be used inside or outside of
normal working hours. It is likely that certain areas of the Care Centre will be inaccessible outside of
normal working hours e.g. to assure security. The PEEP needs to demonstrate that this has been
adequately considered.
If the PEEP Assessment deems that a particular area does not meet the general access requirements for
the resident being assessed then alternative management arrangements will need to be identified. Once
these arrangements have been identified then a new PEEP will need to be undertaken to ensure that the
new location(s) is/are adequate. Additionally, the Assessor should complete new PEEPand sent to the
Person in Charge of the Care Centre.
The PEEP should be updated at least every 3 months or on finding of a risk assessment that’s show the
previous PEEP Form is out of date.One or more of the following sections should be completed by the
Assessor;
A – Mobility, B – Visual Impairment, C – Hearing Impairment, D – General.
Phoenix Safety Training Services does NOT accept any responsibility for the misinterpretation or
assessments carried out by any individual completing the PEEP.
The content of the PEEP Form is subject to COPYRIGHT and cannot be transcribed. If you require any
additional information on the interpretation or use of the PEEP Form please contact Phoenix Safety
Training Services at info@phoenixsts.ie or on 043 3349611.
For more information on evacuation aid visit; http://www.phoenixsts.ie/shop/healthcare.html
For more information on fire safety training in Nursing Home/Care Centres visit;
http://www.phoenixsts.ie/nursing-home-safety/
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 2 of 7

3. Personal Emergency Evacuation Plan Form
Assessor
Name of Assessor;Name
Assessor Position; Choose Position Other; If Other
Date of Assessment; Date Time of Assessment;Hour:Mins
What times or daysare covered by this assessment?Assessment Time/Day
Area of Assessment
Floor; Floor Room No.Room No.
Area of Assessment;
Area of Assessment
Residents Information
Age;Age D.O.B; Date
Nature ofImpairment(s);
Nature ofImpairment(s)
Section A – Mobility
Is the resident a wheelchair user? Yes/No Type;TypeSize;Sizemm
If YES Enter Details
Does the resident use other types of mobility aids?Yes/No Type;Type of Mobility Aid
If YES Enter Details
Can the resident be transferred to an evacuation aid in an emergency with assistance? Yes/No
Enter Details
Type of evacuation aid in use (Safe working load in Kg); Evacuation Aid
Is the evacuation aid the correct type? Yes/No
If NO Enter Details
Where applicable what evacuation aid is required; Evacuation Aid
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 3 of 7

4. Personal Emergency Evacuation Plan Form
Is the evacuation aid the in correct location? Yes/No
If NO Enter Details
Is the evacuation aid in good order? Yes/No
If NO Enter Details
Section B – Visual Impairment
Has the resident a visual impairment? Yes/No
If YES Enter Details
Does the resident require the emergency escape procedure to be on tape/CD/MP3?Yes/No/NA
Does the resident require the emergency escape procedures to be in Braille?Yes/No/NA
If YES Enter Details
Does the resident require the emergency escape procedures to be in large print? Yes/No/NA
If YES Enter Details
Can the resident read the fire notes signs?Yes/No
Enter Details
Have any hazardous projections or other structural components been identified on residents escape
routes? Yes/No
If YES Enter Details
Are all escape routes clearly sign posted to meet residents requirements? Yes/No
If NO Enter Details
Are all escape corridors designed so as to prevent visual confusion in resident’s circumstances?Yes/No
If NO Enter Details
Are all escape staircases fitted with adequate colour contrasting nosing and a suitable
handrail?Yes/No/NA
If NO Enter Details
Section C - Hearing Impairment
Has the resident a hearing impairment? Yes/No
If YES Enter Details
Can the resident hear the fire alarm in normal circumstances? Yes/No
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 4 of 7

5. Personal Emergency Evacuation Plan Form
If NO Enter Details
Does the resident require the centre’s emergency procedures to be provided to them in an alternative
format to the standard written instructions? Yes/No
Enter Details
Where applicable, is resident’s bedroom fitted with a (hard wired) flashing light, and (vibrating pillow)
linked to the fire alarm? Yes/No/NA
Enter Details
Where applicable, is the resident’s (shower/bathroom) fitted with a flashing beacon linked to the fire
alarm? Yes/No/NA
Enter Details
Section D – General
At the intended time of use how many escape routes are available for use?Choose Number
At the intended time of use, how many escape routes are available for residents living with a disabled?
Choose Number
If only one escape route is available how far, approximately (in meters) is the exit from the area/floor
where the resident is to a place of temporary safety or safety? Metersm.
How long approximately would it take to evacuate the resident from the area/floor, record the time in
minutes for each available place of temporary safety or safety up to a maximum of three?
Time 1 Minutes – Time 2 Minutes – Time 3 Minutes
Are all escape routes free from any structural features that will present either a hazard or a barrier to the
resident using any of the available routes? Yes/No
If NO Enter Details
Do any of the escape routes involve escape into an adjoining building or areas allowing for progressive
horizontal evacuation?Yes/No
Enter Details
Does the existing fire escape signage clearly lead you to a place of temporary safety or safety? Yes/No
Enter Details
Is there furniture obstructing in room/area? Yes/No
If YES Enter Details
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 5 of 7

6. Personal Emergency Evacuation Plan Form
Have refuge points been provided on or adjacent to each escape route?Yes/No
Enter Details
Has the evacuation plan been explained to the resident? Yes/No
Enter Details
Can the resident raise the alarm if they discover a fire (operate the manual call point)? Yes/No
If NO Enter Details
In an emergency can the resident contact staff in the area in which the resident is located? Yes/No
If NO Enter Details
Does the resident required assistance to get out of their bedroom in an emergency? Yes/No
If YES Enter Details
Can the resident move quickly in the event of an emergency? Yes/No
If NO Enter Details
Is the resident on oxygen therapy? Yes/No
If YES Enter Details
Has staff practiced appropriate evacuation drill to meet the resident’s needs? Yes/No
If NO Enter Details
Is there an up-to-date record of staff receiving training in the use of evacuation aids? Yes/No
If NO Enter Details
Does the resident’s bedroom and bedroom door have an appropriate level of fire resistance? Yes/No
If NO Enter Details
Is the resident’s bedroom door fitted with smoke seals and in good order?Yes/No
If NO Enter Details
Have all possibilities for relocating the activity or service provision on the ground floor (of this or any
other building) been exhausted?Yes/No
Enter Details
Are you aware of any other measures that could be introduced in the Care Centre under assessment that
could further aid the resident’s evacuation in case of an emergency? Yes/No
If YES Enter Details
Number of staff required providing assistance to resident? Number of Staff
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 6 of 7

7. Personal Emergency Evacuation Plan Form
How long would you estimate that it would take to evacuate the resident (other than with the help of any
items identified above), in the event of an emergency? Time Minutes
Other Information;
Other Information
As the Assessor do you denote that the Care Centre is suitable for the resident? Yes/No
Signed (Assessor) _________________________________
© Phoenix Safety Training Services – Unit 21, Redleaf House, Townspark, Longford.
Tel/Fax: +353 (0) 43 3349611 Email:info@phoenixsts.ieWeb:www.phoenixsts.ie
V2.5 – Page 7 of 7