OMB Control No. 0693-0051
Expiration Date: 08-31-2011
Questionnaire on Emergency Evacuation Procedures
Purpose |
This survey is being conducted by the National Institute of Standards and Technology (NIST), an agency of the U.S. Department of Commerce, in order to improve the emergency procedures of this building. We ask that you complete this survey about your participation in the evacuation that occurred on February 19, 2010.
Completing this questionnaire is voluntary, but your assistance would be greatly appreciated to help improve the safety of the building occupants.
Please return this questionnaire to XXXXX |
SECTION 1: Please answer the following questions about the time period between being alerted (e.g., from the alarm) to the incident in this building and entering the stairwell/elevator/exit. |
Your own office/room Restroom Cafeteria Stairwell Colleague’s office/room Elevator Basement Storage / copy area Meeting room Corridor First floor lobby Other, specify _____________ |
(2a) On which floor were you located when you first became alerted to the incident? _______ (2b) What were you doing? ________________________________(e.g., working) |
(3) How did you first become alerted to the incident? Mark all that apply. Alarm tone Voice alarm message to evacuate Voice alarm message to wait on floor/remain on floor Flashing strobe light Manager of company/Boss Evacuation coordinator/fire warden/fire safety staff for building Colleague/coworker Smoke (dark/dense) OR Smoke (light/diluted) Flames/fire Other, please specify ______________________________________________. |
(4) What did you think was going on? Real fire emergency False alarm (the alarm is sounding by mistake) Test of equipment Regularly scheduled fire drill Security situation Weather emergency I didn’t know what was going on Other, please specify ________________________________________________. |
(5) Once you were alerted to the incident, did you receive any instructions on where to go or what to do from one of the following? If yes, mark all that apply in the order that you received these instructions beginning with (1) until you entered the stairwell/exit. _____Voice alarm message (What did the message say? _______________________) _____Manager of company/Boss (What did he/she say? _______________________) _____Evacuation coordinator/fire warden/fire safety staff for building (What did he/she say? _____) _____A colleague/coworker (What did he/she say? _______________________) _____Other, please specify _______________________________________________________. |
(6) Please number the following actions from what you did first (1) after the first alert to what you did next (2), and continue to number all of the actions that you performed until you entered the stairwell/exit. Please number the following actions (only those that apply) on the lines provided. If necessary, you can number the same action more than once.
_____Continued prior activity. _____Waited
(based
on alarm instructions ,
based on management instructions )
_____Looked around.
_____Sought more information about the alarm/alert. (Where did you go? _________________)
_____Gave instructions to others on what to do. _____Discussed with others (inside the building , outside of the building ). About what? _____________________________________________________________ _____Looked for others in the building. _____Gathered coat / shoes/valuables, dressed. (What things? __________________________)
_____Gathered emergency/coordinator supplies. (What things? __________________________) _____Saved file/turned off computer. _____Secured files/documents. _____Secured office/room/space (shut door , turned out light(s) , other? __________________).
_____Other, please specify _______________________________________________________. _____Other, please specify _______________________________________________________. |
(7a) Could you see others around you on the floor? Yes No (7b) If yes, How many? 1-2 3-5 6-10 11-20 21+ What were they doing? _______________________________________________. |
(8a) Did you feel at risk (in danger) at any time before you entered the stairwell? Yes – high level Yes – moderate level No |
(8b) If yes, did your feeling of risk (in danger) increase before your entered the stairwell? Yes No
(9) What was the main thing/reason that made you decide to evacuate? _______________________________________________________________________. |
(10) How much time passed from the moment that you became alerted to the incident until you entered the stairwell/elevator/exit? __________min.
|
SECTION 2: Please answer the following questions about the time period between entering the stairwell/elevator/exit and leaving the building. |
(11a) How did you evacuate the building? Stairwell Elevator Both Stair and Elevator Walked directly outside to exit Other, please specify _____________________________________________________. (11b) If you used an elevator, what was your primary reason for not using a stairwell? I
have a condition that requires me to use an elevator.
Elevators
are easier to use (physically).
(11c)
How did you find the stairwell/elevator/exit that you used to
evacuate from
your floor?
I followed EXIT signs. I
knew the exit. I was instructed to use this exit. Other, please specify ______________________________________________________. |
(12) If you left by a stairwell, (a) Did you use… Stairwell __ Stairwell __ (b) Please check any of the conditions you encountered during the evacuation:
|
(13a) During your evacuation, could you see others around you (e.g., in the stairwell)? Yes No (13b) If yes, were they the same people from your floor? Yes No |
(14a) From the time you entered the stairwell/elevator/exit until you left the building, how many minutes passed? ________min.
(14b) What time was it when you exited the building? ________ (e.g., 10:30 am)
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(15a) Did you receive information or instructions that influenced your behavior while in the stairwell/elevator? Yes No;
(15b)
_____Voice alarm message (What did the message say? _______________________) _____Manager of company/Boss (What did he/she say? _______________________) _____Evacuation coordinator/fire warden/fire safety staff for building (What did he/she say? _____) _____A colleague/coworker (What did he/she say? _______________________) _____Other, please specify _______________________________________________________.
|
(16) When you exited the building, which exit did you use? Exit ___ Exit ___ Exit ___ Exit ___ Other, please specify _____________________________________________________. |
(17) Did any of the following conditions make your evacuation more difficult?
|
SECTION 3: Please provide background information about you and your experience with building evacuations. |
(18) Have you ever been in a building fire before (where you saw smoke or flames and/or you felt at risk)? No Yes, in this building Yes, in another building |
(19) What year did you begin living/working in this building? _________or N/A (e.g., visitor). |
(20) How many times do you remember the fire alarm sounding in this building in the last year? None 1 or 2 times 3 to 5 times 6+ times |
(21) Have you received any form of fire emergency training for this building? No Yes, but not in the past 12 months. Yes, in the past 12 months. |
(22a) If yes, how did you receive the fire emergency training (check all that apply): Pamphlets or guides Video Seminars or presentations Evacuation drills/practice drills Other, please specify ____________________________________________________.
(22b) How many fire drills have you participated in for this building in the last year? None 1 or 2 3+ |
(23a) Are you aware of the fire evacuation procedure for this building? Yes No (23b) If yes, please describe: ___________________________________________________________________________. |
(24a) Sex: M F (24b) How old are you? 18-25 26-35 36-45 46-55 56-65 66+ (24c) Current status: Currently married Widowed Divorced Separated Never married (24d) Do you have any children (under 18)? Yes No (24e) Highest level of education: Some high school High school graduate Some college College degree Advanced degree (24f) What is your native language? English Spanish Other, please specify __________. (24g) Are you an evacuation coordinator/fire warden for this building? Yes No (24h) Are you a manager for your office/company? Yes No |
Any Additional Comments:
|
Thank
you for taking the time to help us improve
emergency procedures
and safety!
NOTE: This questionnaire contains collection of information requirements subject to the Paperwork Reduction Act (PRA). Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subject to penalty for failure to comply with, a collection of information subject to the requirements of the PRA, unless that collection of information displays a currently valid OMB Control Number. The estimated response time for this questionnaire is 10 minutes. The response time includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this estimate or any other aspects of this collection of information, including suggestions for reducing the length of this questionnaire, to the National Institute of Standards and Technology, Attn., Erica Kuligowski, erica.kuligowski@nist.gov, 301-975-2309.
File Type | application/msword |
File Title | Questionnaire on Emergency Procedures |
Author | Darla Yonder |
File Modified | 2010-04-28 |
File Created | 2010-04-28 |