emergency reporting form (plant operations)

EMERGENCY REPORTING FORM

Information of Person Reporting Incident:

Name: Title:

Department: Building:

Office Phone: Cell Phone:

Email:

Emergency Information:

Space Occupant:

Facility Zone: Bldg./Loc.: Room: Type of Space: Classroom Research Office Lab Infrastructure

Residence Hall Room Other:

Are there any life safety dangers or risks as a result of this emergency? If so, have emergency services (Fire, UHPD,

EHS, etc…) been notified? Yes No

Is there any one trapped or stranded: Yes No Are the exits blocked? Yes No

How many occupants are there in the impacted space?

Provide a brief overview of the nature of the emergency. (Fire, Excessive Water, etc.?)

Describe visible damages to property. (What things are affected? How many rooms are under water? )

Describe any other relevant information regarding this incident or subsequent impacts you want to report.

FM Onsite Contact: ________________________________ Call Center Rep: ___________________________________ Date & Time:_ ____________________________________ Local Response Dispatched: _________________________ Response Time: ___________________________________ Cotton Assistance Required? Yes No If yes, who dispatched? ____________________________ when? _____________________________________ Confirm Cotton arrival: ____________________________ Has service level order been processed? Yes No