Resident Evacuation Tracking Roster

Roster used during an evacuation to account for every resident, record movement status, and document destination and reunification details.

Evacuation Event Details

• Facility Name
• Evacuation Date
• Evacuation Time
• Reason for Evacuation
• Incident Reference Number
  Optional internal incident, drill, or event reference for audit trail purposes.

Resident Identification

• Resident Full Name
• Resident ID or Chart Number
  Use the facility's internal identifier if available. Do not collect SSN.
• Unit or Room Number
• Resident Status

Evacuation Movement Tracking

• Evacuation Method
  Select all that apply.
• Destination Type
• Destination Name
• Transfer Time
• Accompanying Staff Member

Special Assistance and Safety Notes

• Special Assistance Needed?
• Assistance Types
  Select all that apply.
• Safety Notes
  Include only essential information for evacuation and immediate care. Avoid unnecessary PII.
• Medication or Equipment Accompanied Resident?

Accountability and Reunification

• Resident Accounted For?
• Reunification Status
• Reunification Date
• Follow-Up Required?

Submitter and Verification

• Submitted By
• Job Title
• Contact Phone
• Verification Signature
  Optional signature for post-incident verification and audit trail.