DHHS Home Page NC DHHS On-Line Manuals  
     DHHS Manual Home Manual Admin Letters Change Notices Archive Search Index Help Feedback

Previous PageTable of ContentsNext Page



Section V:

Human Resources


Safety and Benefits


Emergency Action Plans

Current Effective Date:


Revision History:


Original Effective Date:




To establish a requirement and method of developing Emergency Action Plans for

emergencies to include fire, bomb threats, severe weather, internal and external evacuations, to assure employee response and training in emergency response, to establish guidelines for the appointment and actions of Emergency Response Personnel who will be responsible for executing the Emergency Action Plans.


Division/Facility/School Directors shall ensure all division/facility/school employees receive emergency response information and training as required by Joint Commission, NC Fire Code and OSHA 1910/1926 Industry and Construction Standards.


  1. Emergency Evacuation Coordinator – Person designated for each building by the Division/Facility/School Director with the responsibility to be in charge of the building evacuation process and management of the Emergency Evacuation Plan and requirements therein. The EEC will be the primary point of contact for the building evacuation status and responsible for communicating that information to division/facility/school management and the responding Emergency Management Services personnel as well as providing specific building information as required.

  2. Fire /External Evacuation - Evacuation in the event of fires and other building emergencies, where employees will follow predetermined routes to the exterior of the building and gather at a designated collection point., or evacuations in the event of bomb threats, chemical spills, or other emergencies outside the building where a predetermined route and assembly area is not safe or feasible, and employees must be directed to specific routes and assembly areas based on the emergency and its location.

  3. Floor Monitor – Persons designated with the responsibility of assisting the EEC by ensuring that all persons are evacuated from the building during execution of the Emergency Evacuation Plan. The Floor Monitor shall be accountable for their designated areas and the assurance that all persons have safely exited the building and reporting the evacuation status of their designated area to the EEC.

  4. In-Building Evacuation - Evacuation in the event of tornadoes, severe inclement weather, or other emergencies where the employees must remain in the building and gather in an inside safe area.

Roles and Responsibilities

  1. Emergency Evacuation Coordinator (EEC) Responsibilities:
    1. The EEC will be in charge of the building evacuation process. He/she will coordinate in-house activities during emergency and drill evacuations and will assist outside services as needs are indicated. The EEC will have final authority to issue the notice for building re-entry. He/she will further have responsibility to train Floor Monitors on their responsibilities and will address evacuation problems with responsible parties. The EEC will establish a control center to coordinate evacuation activities. The EEC will identify an alternate control center. The EEC will develop a Floor Monitor List for each floor and include it as part of the Emergency Building Evacuation Plan. The list will be kept current by the EEC and posted on each floor (or by other readily accessible means, ie. division/facility/school intranet).

    2. The EEC will be responsible for ensuring Emergency Evacuation Drills are properly documented. Pursuant to the North Carolina Fire Prevention Code, recordkeeping shall include:
      1. Identify the person conducting the drill.

      2. Date and time of the drill.

      3. Notification method used.

      4. Staff members on duty and participating

      5. Number of occupants evacuated.

      6. Special conditions simulated.

      7. Problems encountered.

      8. Weather conditions where occupants were evacuated.

      9. Time required to accomplish complete evacuation.
  2. Floor Monitors Responsibilities:
    1. The floor monitor will verify that the emergency exits are usable and verify that each office/area in their area of responsibility is evacuated.

    2. Except in weather related emergencies, the Floor Monitor will proceed to the designated Control Center and inform the Emergency Evacuation Coordinator (EEC) of their floor/wing evacuation status. In the event of a. weather related emergency, the monitor should report to their designated evacuation collection point.

    3. Floor monitors will maintain a current list of persons with disabilities and advise the Emergency Evacuation Coordinator (EEC) of their special evacuation needs should an event arise.

    4. In the event of a bomb threat, monitors shall check all work area spaces and common areas (bathrooms, conference rooms, hallways etc) on their floor and report anything that appear to be out of place or unusual to the Emergency Evacuation Coordinator.

    5. Floor Monitors shall not open doors to offices, storage rooms, file cabinets etc during their area checks.
  3. Employee Responsibilities:
    1. Employees will immediately evacuate in an orderly fashion upon alarm and/or Floor Monitor's direction.

    2. Employees will report to the designated internal or external evacuation collection points as determined by the emergency and remain there until such time that the EEC gives the “All Clear” to return to their work area.

    3. Employees shall adhere to the requirements of this policy and its associated procedures.

    4. Employees failing to abide by directions to evacuate the facility may be subject to disciplinary action.


  1. Each Division/Facility/School Director shall appoint an Emergency Evacuation Coordinator (EEC). The EEC will appoint (with management concurrence) two Floor Monitors (primary & alternate) for each building floor and or wing. Directors of Hospitals, Schools and Residential Facilities may develop procedures that meet the intent of this requirement using other named positions of responsibility.

  2. Each Division/Facility/School Director shall ensure the development of a written Division/Facility/School Emergency Action Plan that contains an Emergency Evacuation Plan for each building within their authority and shall make it available to all affected employees.
    1. The Emergency Action Plan shall at minimum, include the following elements:
      1. Fire Exit Evacuation Procedures (External Evacuation)

      2. In-Building Evacuation Procedures (temporary shelter-in-place)

      3. Procedures for complete Facility Evacuation and/or shelter-in-place (where applicable)

      4. Bomb Threat Procedures

      5. Severe Weather Procedures

      6. Building Utilities Failure Procedures

      7. Campus Lockdown Procedures
    2. For each element, the Emergency Evacuation Plan at a minimum, shall include:
      1. The designation and duties of Division/Facility/School Emergency Response Personnel who will assist and direct actions during an emergency situation.

      2. Designation and locations of primary and secondary Evacuation Collection Points.
        1. The collection point (s) shall be located appropriately to protect the evacuees from the hazard (s) requiring evacuation and shall not create an obstruction or delay to the emergency response personnel.

        2. The external evacuation collection point shall be at least 500 feet from the building or located in Area of Refuge that protects the evacuees from any hazards associated with the evacuation causing event.
      3. The primary and secondary routes of egress from each portion of the building to the Evacuation Collection Point.

      4. The designation and locations of an Area of Refuge shall be pre determined for all building evacuation scenarios.

      5. The means available to identify and evacuate handicapped persons.

      6. The means to be used to notify building occupants to evacuate.

      7. The means to be used to account for all occupants in the collection points.

      8. The means whereby occupants will be notified that the building may be safely re-entered.

      9. For External Evacuations, upon completion of the accountability of all building occupants and the determination that returning to the building from the Primary and or Secondary Collection Point will not be possible, building evacuees shall be immediately relocated to the designated Area of Refuge.

      10. The means to be used to report emergencies to the proper authorities.

      11. The responsibilities of division/facility/school staff not affected by an emergency to assist in required emergency response efforts.

      12. The means of coordination with responding Emergency Management Services Personnel.
  3. If the building relies on an automatic detection/alarm system, each element shall include a means to initiate evacuation in the event that the alarm system is not operational.

  4. The means to shutdown the appropriate building utility (s) system (s) and secure the building from exposure to exterior airborne hazards.

  5. Each division/facility/school shall provide for training of all employees within each building.
    1. Employee training shall include the following:
      1. The requirements of the plan

      2. Evacuation routes

      3. Areas of refuge

      4. Collections points

      5. Accountability procedures

      6. Additional response requirements to assist other buildings during an emergency
    2. Employees shall be trained upon initial employment, annually through the exercise of drills, fire safety training and shall be retrained each time the plan is significantly changed.
  6. The Emergency Action Plan shall be tested through drills, in which all employees shall participate. Fire drills will be conducted using the schedules and guidance found in the DHHS Fire Prevention Plan Policy. Drills will be held at unexpected times and under varying conditions to simulate the unusual conditions that occur in the case of an emergency. Drills will be conducted when a majority of employees will be present to participate in the drill.

  7. Each residential facility shall develop a plan for the mass evacuation of the facility for a catastrophic event. This plan will include the necessary information for moving all persons exposed to the event and the logistical requirements expected. Specific consideration shall be given to on-hand Division/School/Facility transportation, available personnel, time to move all persons, and unique requirements of support (i.e., medications, powered medical devices, support equipment, etc.). The purpose of this information is to be able to quickly respond to requests for additional assets required for evacuation, from local, state, and federal agencies in the event of forced evacuation.

  8. The Safety Program Manager shall develop general operating procedures to guide Divisions/Facilities/Schools in developing their specific procedures.

  9. Each Division/Facility/School shall develop specific operating procedures for the implementation of this policy.


For questions or clarification on any of the information contained in this policy, please contact Human Resources. For general questions about department-wide policies and procedures, contact the DHHS Policy Coordinator.

Previous PageTop Of PageNext Page


     DHHS Manual Home Manual Admin Letters Change Notices Archive Search Index Help Feedback