Safety Checklist Program for Schools

October 2003
DHHS (NIOSH) Publication Number 2004-101

Emergency Action Plan (Template)

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Emergency Personnel Names and Phone Numbers

Emergency Personnel Names and Phone Numbers

DESIGNATED RESPONSIBLE OFFICIAL (Highest Ranking Manager at
_____________site, such as __________, ___________, or ____________):
Name:_______________________________________ Phone: (________________)
EMERGENCY COORDINATOR:
Name:_______________________________________ Phone: (______________)
AREA/FLOOR MONITORS (If applicable):
Area/Floor:__________________ Name:_______________________________

Phone: (_______________)

Area/Floor:__________________ Name:_______________________________

Phone: (_______________)

ASSISTANTS TO PHYSICALLY CHALLENGED (If applicable):
Name:______________________________________ Phone: (________________)
Name:______________________________________ Phone: (________________)
Date ____/____/____

Page last reviewed: June 6, 2014