Emergency and Time Sensitive Reporting Emergency/Time Sensitive Shift Report Used for emergencies and time sensitive notifications. Please note, the submissions in this form will be forwarded to other interested parties, so please keep all submissions fact based and professional. PLEASE ONLY COMPLETE ONCE YOU ARE SAFE Your Name * Your Role * Building Manager Pub Attendant Barista Performance Technician Event Ambassador Professional Staff Date of Incident * Time of incident * Location of Incident * Ida Noyes Hall Reynolds Club Mandel Hall Bartlett Hall Harper Cafe Cobb Coffee Shop Ex Libris Cafe OtherOther Emergency or Occurrence (including false alarms) * Medical Emergency Fire Violent Threat Security Incident Protest or Demonstration (in building) Severe Weather or Environmental Power Outage Facilities Emergency Were Emergency Services Notified? * I called 911 I called UCPD (123) Someone else called 911 Someone else called UCPD (123) Emergency Services were already aware Emergency Services were not needed If UCPD responded, please ask them for their report number Was a Dean On Call Involved? * Yes, there was a Dean On Call onsite Yes, someone called or messaged the Dean On Call. No, there was no Dean On Call involved Unknown If you contacted a professional supervisor, who? Medical Emergencies Individual names and medical information will be protected. These are not distributed to non-essential staff. Name of Person Impacted Was this person alone? * With a family member With a friend With an unknown person Alone/Unassisted Name of person providing support Was individual responsive? Awake and fully coherent Conscious, but incoherent Unconscious or Unresponsive Unknown Type of Medical Emergency Muscular or skeletal injury (breaks, sprains, etc...) Open wound injury (cut, puncture, abrasion, etc...) Burn Cardiac (heart attack, chest pain, afib, etc...) Stroke Respiratory (breathing, asthma, etc...) Choking Diabetic (hypoglycemia, hyperglycemia) Seizure Allergic reaction Alcohol or substance related Mental health emergency OtherOther Unknown Did you provide any of the following services? First Aid (injuries) CPR (cardiac/respiratory) Abdominal Thrusts (choking) Mobility Assistance Contacting someone for them Were any of our medical supplies used or distributed? * AED Naloxone (NARCAN) Medical Gloves CPR Supplies (mask) First Aid Supplies Important to note so we can restock EMS Response * Ambulance responded and transported patient Ambulance responded, patient denied care No EMS response Fire Emergencies If anyone was injured, please also check the medical emergency box. Was there an actual fire? * Fire Identified Smoke Identified Not Found Was the fire alarm activated? * Fire Alarm sounded automatically I activated the pull station Somebody else activated the pull station Alarm did not sound Was the building evacuated? * Yes, everyone evacuated Yes, but some people refused No, the building was not evacuated Was a fire extinguisher used? * I used a fire extinguisher Another staff member used a fire extinguisher. Name:Another staff member used a fire extinguisher. Name: Caterer or vendor used a fire extinguisher A fire extinguisher was used, but I don't know who used it No fire extinguisher was used Was there any damage? * Damage to facility Damage to equipment No Damage Violent Threat How did you become aware of the threat? Saw or heard Notified by another individual Campus Alert How did you maintain your safety? * Evacuated Sheltered in place Where was the threat? * At my location At another location on campus Unknown Security Incident Type of security incident * Someone refusing to leave Someone acting suspicious Theft of Equipment or Personal Belongings Unauthorized Access/Break-In Vandalism/Damage to Property Suspicious package or item Verbal altercation between two people or groups Smoking or substance use in building OtherOther Protest or Demonstration Protests are a regular occurrence on college campuses, and peaceful protesting is supported on campus as a form of free expression. This form is purely to keep us informed that a protest happened, along with the general timeline and details. Submitting a report is not intended to penalize individuals or discourage expression. You do not need to identify any fellow students you observed as part of the protest. General topic/cause of the protest * Rough estimate of the number of people protesting * 500 If any damage occurred, intentional or unintentional, please provide an overview. You may also check the "Facilities Emergency" box to note specific facility issues. Severe Weather or Environmental Emergency If anyone was injured, please also check medical emergency. If anything was damaged, please also check facilities emergency. What emergency conditions occured? * Tornado Thunderstorm/Lightning Hail Extreme Rain/Flooding Heavy/Damaging Winds Blizzard/Heavy Snow Earthquake OtherOther Check all that apply How did you become aware of the emergency? * Observation Weather or News Report Campus Alert Notified by another staff member. Name:Notified by another staff member. Name: Notified by a client or customer Did any of the following become necessary? Shelter indoors Move to a lower level Move to interior room (away from windows) Move to a higher level (away from flooding) Power Outage Did Emergency Lights Activate? * Yes Yes, but not all No Did you have access to a flashlight? * Yes No, but I had my own device No Please note the location of any emergency lights that didn't turn on. * What time was power restored? * Power was restored at:Power was restored at: Power has not currently been restored Power was not restored by the end of my shift Facilities Emergency Type of Emergency * Water Electrical Structural Utility Failure IT Outage Hazardous Cleanup (Blood, Feces, Chemical) OtherOther Please provide a narrative overview * Detail, including times and locations where possible, is appreciated. If any events were disrupted, please describe so that we may follow up with the impacted event organizers Were you able to re-access the building? * I never left the building Yes. I was able to resume my job. Yes. I was able to return to shutdown/lock up No. Access was not needed No. Something will need to be secured or shutdown. Were you injured in any way during this incident? * Yes, minor injury Yes, I need(ed) medical attention No, I am safe and uninjured Captcha Submit If you are human, leave this field blank.
