Personal Emergency Evacuation Plan (PEEP) Request Form

Personal Emergency Evacuation Plan (PEEP) Request Form

Fill out this form if you feel you require a Personal Emergency Evacuation Plan (PEEP) to exit the campus buildings in the event of an emergency, or otherwise if you are a staff member and have been asked to fill the form out on behalf of the intended PEEP holder (the term used when referencing the person requiring a PEEP throughout this form). A School staff member may be asked to fill this form out on behalf of a student, staff member or applicant/visitor if an evacuation risk is identified by Health and Safety trained staff from the Luminate Safety, Health and Environmental Services team (SHE). Further general information can be found on the following webpages:

How answers will be used (read to intended PEEP holder if not self-filled)

Any PEEP draft created from this form submission will be sent to the intended PEEP holder and the SHE Services team, whilst a copy of the form responses will be sent to the form-filling staff member for their records (if not self-filled). The Estates team will also receive a copy of the draft PEEP to enact the Redacted PEEP Form page during emergency scenarios.

Once SHE Services have reviewed a draft PEEP document, they may decide that a meeting is necessary with SHE Services/School staff to discuss the contents of the plan. SHE Services may also request a meeting with the intended PEEP holder to run through a practice evacuation if they identify any Health & Safety risk indicators from the PEEP draft.

Full name of the person requiring a PEEP*

This person will be referred to as the intended PEEP holder from here forwards

Email address of the intended PEEP holder*

Please provide the email address of the person requiring a PEEP.

Enrolled students should provide a Leeds Conservatoire email address

Contact number of the person requiring PEEP*

Please provide the intended PEEP holder's current contact number

Phone

Is the intended PEEP holder an enrolled student, staff member, visitor/applicant or Leeds Junior Conservatoire student?*

Select

Student ID (enrolled students only)*

Enrolled students only

If the intended PEEP holder is an applicant, please revisit the previous question and select Visitor/applicant and answer the query called Purpose of visit stating 'Applicant'.

Job title (staff members only)*

Staff only

If the intended PEEP holder is an applicant, please revisit the previous question and select Visitor/applicant and answer the query called Purpose of visit stating 'Applicant'.

Purpose of visit (visitors, applicants or LJC)*

Visitors, applicants or Leeds Junior Conservatoire students only

Please state the purpose of your visit if your are a visitor, state 'Applicant' if you are applying to study or 'Leeds Junior Conservatoire student' if attending LJC organised events

Who is filling out this form?*

Select

Full name of the person filling out the form*

If you are filling this form out to request a PEEP for yourself, please revisit the previous question and select I am the person who requires a PEEP (the intended PEEP holder)

Job title of the person filling out the form*

Email address of the person filling out the form*

Is this PEEP required for long-term or short-term reasons?*

Select

Please provide the estimated duration that this temporary PEEP will be required for*

E.g. 3-6 months

Select the options that are relevant to the intended PEEP holder's request*

Please select as many options as required.

Please use the Other option and give details if conditions/difficulties are not available

Select

Please detail any other difficulties or conditions that the PEEP holder wishes to share in relation to this request*

Please give a brief description of the intended PEEP holder's reasons as to why they require a Personalised Emergency Evacuation Plan*

Can the intended PEEP holder raise the fire alarm in an emergency?*

Select

Can the intended PEEP holder descend stairs unaided in an evacuation?*

Wheelchair users and those with mobility difficulties should wait in the Refuge

Points labelled on Floorplans, which can be found on the Emergency Evacuations including Evacuation Chair and Refuge Point Locations page on the external website.

Select

Does the intended PEEP holder require the use of an Evacuation Chair to evacuate in an emergency?*

Although wheelchair users and those with mobility difficulties may require the use of an Evacuation Chair, those with other conditions may also require use of this evacuation method (for example, some people who have seizures)

Select

Can the intended PEEP holder self-transfer into an Evacuation Chair in an emergency evacuation?*

Select

Which campus buildings will the intended PEEP holder be using?*

Please select as many options as required.

Select

Which of the following activities will the intended PEEP holder be engaging in at Leeds Conservatoire?*

Please select as many options as required.

Please use the Other option and give details if they will be left alone to study, work or visit.

Select

Please explain what other activities the intended PEEP holder will be engaging in?*

If the intended PEEP holder requires any specialised alarm systems, please provide details below.

E.g. text alerts, vibrating fire alarm pagers, flashing beacons etc.

If not, please leave blank.

If the intended PEEP holder has any coping strategies for emergency evacuations, please gives details below.

Coping strategies e.g. breathing exercises or soothing practices.

If not, please leave blank.

If the intended PEEP holder requires any other additional assistance for emergency evacuations, or requires the use of a Refuge Point, please give details below.

If the intended PEEP holder requires the use of a Refuge Point, please detail how they will reach a Refuge Point in this box.

If not requiring a Refuge Point, or requiring any additional assistance, please leave blank.

Please select 'PEEP holder has agreed' once the intended PEEP holder has confirmed they've viewed relevant floorplans, general evacuation info and familiarised themselves with emergency exit routes or how to reach Refuge Points if required (available on the link below)*

Referenced information on this link: Emergency Evacuations including Evacuation Chair and Refuge Point Locations

Select

Please select 'PEEP holder has agreed' to confirm that the intended PEEP holder still wishes to request a PEEP after reading the general evacuation information, floorplans and familiarised with exit routes/Refuge Points*

Referenced information on this link: Emergency Evacuations including Evacuation Chair and Refuge Point Locations

Select

Privacy and information sharing

Please ensure either as the intended PEEP holder self-filling this form, or otherwise the staff member filling this form on behalf of the intended PEEP holder, that this statement has been read, understood and agreed to before submitting:

The intended PEEP holder fully understands that it is their responsibility to inform the Luminate SHE Services team of any changes to their circumstances that may impact the contents of their PEEP by emailing She.Services@luminate.ac.uk. In order to provide the intended PEEP holder with their PEEP document, SHE Services will keep a record of any communication with them on this matter.

By submitting this form, the intended PEEP holder will be agreeing to their disclosed information from this form to be collected and used to create their PEEP, in accordance with our Data Privacy Policy found on the Luminate Education Group's policy website. This information will be stored in-line with the aforementioned policy securely for 7 years from the date of them leaving Leeds Conservatoire, or otherwise when the data is deemed no longer relevant before then.

The intended PEEP holder can confirm, adapt or remove the information contained on their PEEP document after receiving it by emailing She.Services@luminate.ac.uk. However, please note that if the intended PEEP holder does not contact the above email address, the PEEP draft will be enacted until they do so.

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