Instructions: Complete this form immediately following a classroom evacuation if you have left students in your classroom. HS and MS faculty should send a runner with two copies to their principal. ES faculty should wait for an ES secretary to come by and retrieve the copies. Keep one copy for yourself.
Teacher’s Name:__________________ Class
Room Number:_______
Current Location of Your Class
(Evacuation Site):__________________
Number of Students Left in Classroom:__________________________
Names (If Possible):
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Of Those Left Behind:
Number Apparently Dead:________
Number Gravely Injured: ________
Room Checked:
Yes No
Number and Names of Injured Removed:
Number and Names of Deceased Removed:
Number and Names of Those Taken to Triage: