Personal Emergency Evacuation Plan Request Form

Fire safety legislation requires the University to ensure that all occupants of our buildings can escape to a safe place in the event of a fire or other emergency.

Many people with disabilities are able to evacuate a building without assistance or with minimal help from others. Some individuals may require further assistance and in such cases a Personal Emergency Evacuation Plan (PEEP) is created.

A PEEP is a type of risk assessment that is specific to an individual, and takes into account the nature and/or severity of the Disability, condition or temporary impairment, as well as the building in which that person works, studies or visits.

Please complete this form if you think you are likely to need assistance to escape from buildings in an emergency either temporarily or throughout your studies or work at the University of Roehampton.. Please remember that many of our buildings are multi-storey and that lifts often cannot be used as a means of escape from upper storeys.

Please also note the following provisions to ensure your safety in the event of a fire emergency:

1.  All buildings are fitted with automatic fire detection and alarm systems to provide early detection and warning in the event of an outbreak of fire.

2.  Fire escape routes are signposted using internationally approved symbols to direct building occupants to the nearest exit and relevant Assembly point location.

3.  Refuges are provided on all floors where there is no safe escape route for a wheelchair user. Refuges are temporarily safe places where a person that cannot descend stairs can wait for assistance to escape. All refuges are provided with phones or intercoms and instructions for calling for assistance.

4.  Security staff are available to ensure a safe evacuation

5.  Where available, fire wardens will help to ensure a safe emergency evacuation.

6.  The university has trained staff who will respond to any call from a refuge and are equipped to assist people to escape from the building.

7.  All staff and students receive fire safety information as part of their induction to the University campus.

Your Name
Student ID
Department
Email address / Personal email Address:
University of Roehampton email Address:
Please outline all the buildings you use (refer to Appendix A)
Are you a student or an employee of the University? / Student / Employee
Start date at Roehampton
Accommodation on campus (Students)
Please provide details of your accommodation
Is your need for a PEEP / Temporary? / Permanent?
Which of the following would best describe your Disability please tick all that apply / Physical / Sensory / Mental Health / Autism/
Aspergers / Other
Are you able to raise an alarm or summon help in the event of an emergency? / Yes / No
Do you use a wheel chair or mobility aid?
Please outline whether you are able to transfer independently or if you require assistance. / Wheelchair / Mobility Aid
Please outline whether you have difficulties with any of the following / Using stairs / Walking long distances / Other
Are you able to open manual doors, without support? / Yes / No
If you are Deaf or Hard of Hearing, can you hear a fire alarm? / Yes / No
If you are blind or visually impaired, would you feel able to independently exit the building? / Yes / No
Would you like the opportunity to review your PEEP and be shown Emergency evacuation routes and refuge points during a 1:1 tour? / Yes / No
Is there anything else that would be useful for us to know about your ability to best support you in the event of an emergency evacuation?

Thank you for completing the form. This information will be used to compile your own PEEP and the plan will be discussed with you to ensure that it fully meets your needs. Once completed, your PEEP will be shared with Security, Health and Safety, Disability Services (students) and HR (staff). It is also recommended that you let key people working with you know that you have a PEEP and may need assistance in the event of an emergency.

Please send the completed form to

Health and Safety Office

Estates and Campus Services

Mount Clare

Minstead Gardens

London SW15 4EE

Appendix A

List of Buildings at University of Roehampton

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