<p> Input Form for Model Safe School Plan, Volume 2 – Emergency Procedures</p><p>Instructions: Print this Input Form and write in information before attempting to complete on your computer. Complete this form and submit with attachments to Local District Office for review. Local District will forward this information to OEHS. OEHS will enter this information using the Model Safe School Plan, Volume 2 Template – Emergency Procedures, and forward completed draft for your review. Copies of the Model Safe School Plan, Volumes 1 and 2 are available at www.laschools.org/oehs. Questions may be directed to OEHS at (213) 241-3199. </p><p>School Phone Street Address Zip Code City Location Code District</p><p>Emergency Phone Numbers2:</p><p>Name Phone Organization Phone Principal Electric Company Assistant Principal1 Gas Company LD Facilities Director Sewer Authority LD Superintendent Water Company School Operations Nearest Hospital Office of Communications Nearest Medical Clinic School Nurse Fire Station Bus Dispatch Police/Sheriff Department</p><p>Incident Command Team (responsible for directing and documenting emergency activities): </p><p>Incident Commander (Principal) Agency Liaison Responsible for directing emergency operations Coordinates with outside agencies</p><p>Backup Incident Commander Backup Agency Liaison</p><p>Public Information Officer Safety Coordinator Official spokesperson during emergencies Ensures emergency activities conducted safely</p><p>Backup Public Information Officer Backup Safety Coordinator </p><p>Primary Back-up (if primary unavailable) Indicate where the Incident Command Team will meet during an emergency</p><p>Team Assignments (Fill in team leaders, alternates and members. Indicate locations where team will convene during an emergency)</p><p>Search and Rescue Team 1 Leader: Search and Rescue Team 2 Member 1: Performs search and rescue operations Alternate: Performs search and rescue operations Member 2: Member 1: Member 3: Meeting location (inside): Member 2: Member 3: Back-up location (outside):</p><p>Search and Rescue Team 3 Member 1: Search and Rescue Team 4 Member 1: Performs search and rescue operations Member 2: Performs search and rescue operations Member 2: Member 3: Member 3: </p><p>Input Form, OEHS Model Safe School Plan – Volume 2, Emergency Procedures (05-01-03) Ver 2.0 1 Los Angeles Unified School District Office of Environmental Health and Safety (213) 241-3199 Security / Utilities Team Leader: First Aid / Medical Team Leader: Ensures site security of the school site and Alternate: Ensure first aid supplies available and administered Alternate: short-term repairs Member 1: Member 1: Meeting location (inside): Meeting location (inside): Member 2: Member 2: Member 3: Member 3: Back-up location (outside): Back-up location (outside):</p><p>Assembly Area Team Leader: Fire Suppression / HazMat Team Leader: Ensures safe evacuation and accounting of all Alternate: Extinguish fires and evaluate chemical spills Alternate: students and staff Member 1: Member 1: Meeting location (inside): Meeting location (inside): Member 2: Member 2: Member 3: Member 3: Back-up location (outside): Back-up location (outside):</p><p>Psychological First Aid Team Leader: Supply / Equipment Team Leader: Provides psychological counseling for students Alternate: Ensures adequate supplies and equipment Alternate: and staff Member 1: Member 1: Meeting location (inside): Meeting location (inside): Member 2: Member 2: Member 3: Member 3: Back-up location (outside): Back-up location (outside):</p><p>Request Gate Team Leader: Reunion Gate Team Leader: Process request for student pick up Alternate: Reunites parents or guardians at Reunion Gate Alternate: Member 1: Member 1: Meeting location (Outside): Meeting location (Outside): Member 2: Member 2: Member 3: Member 3: </p><p>Documentation (Optional) Primary: Communications (Optional) Primary: Maintains emergency log including financial Alternate: Analyzes situation and updates Incident Command Alternate: information</p><p>Plant Manager School Safety Planning Committee Chair </p><p>Complex Project Manager Keeper of Parent List Information </p><p>Plans for Loss of Utilities (Indicate specific plan for establishing alternative water, electricity and natural gas supply, and alternative method of communication). </p><p>Water (Plan should include alternative water source for drinking water, fire suppression, food service and toilets): Toilet: Drinking Water: Food Service: Fire Suppression: </p><p>Electricity (Plan should provide alternative electrical source for ventilation and emergency lighting): Ventilation: Electric Lights: </p><p>Input Form, OEHS Model Safe School Plan – Volume 2, Emergency Procedures (08-20-03) Ver 2.0 2 Los Angeles Unified School District Office of Environmental Health and Safety (213) 241-3199 Other: </p><p>Natural Gas Food Service: Other: </p><p>Communication Telephone Service: Other: </p><p>Other Information (attach the following information to this form and mail to your Local District Coordinator):</p><p>Site Plot Plan - Annotate and attach your school Site Plot Plan you received from OEHS/FDU indicating location of the following:  command post ( “C”)  assembly area ( “P”)  fire extinguishers ( “F”)  back-up assembly area ( “B”)  emergency supply container ( “S”)  evacuation routes to assembly areas (draw lines)  water shutoff valve ( “W”)  kitchen ( “K”)  gas shutoff valve ( “G”)  first aid center ( “FA”)  bus drop-off and pick-up points ( “DO” and “PU”)  Reunion Gate ( “R”)  electricity shutoff switch ( “E”)  Request Gate ( “Q”) Vicinity Map - Annotate and attach your school Attendance map or the Thomas Bros Map you received from OEHS/FDU indicating location of the following:  perimeter of off-site assembly area ( “P”)  perimeter of backup off-site assembly area ( “B”)  evacuation routes to off-site assembly areas (draw lines)  cross streets of off-site assembly areas (indicate names)</p><p>Principal or Assistant Principal responsible for preparing Emergency Response Plan: Phone No. Date</p><p>Local District Office Use Only:</p><p>Local District Reviewer: Date</p><p>Input Form, OEHS Model Safe School Plan – Volume 2, Emergency Procedures (08-20-03) Ver 2.0 3 Los Angeles Unified School District Office of Environmental Health and Safety (213) 241-3199 1 Assistant Principal responsible for preparing school emergency plan 2 Use emergency phone numbers if available</p><p>Input Form, OEHS Model Safe School Plan – Volume 2, Emergency Procedures (08-20-03) Ver 2.0 4 Los Angeles Unified School District Office of Environmental Health and Safety (213) 241-3199</p>