Emergency Closing Form

Emergency Closing Form

Instructions

Please complete the form in its entirety. Fields with an "*" are required.

Agency or UNC System Campus*

Select or enter value

Facility or Building Name

Address*

Enter the physical address of the facility that is closing.

City*

Zip Code*

Date of Submission*

Contact Name*

Please enter the Name of the individual OSHR can contact with questions regarding the Emergency Closing.

Contact Title*

Enter the Contact employee's Job Title.

Contact Email*

Please enter the Contact Employee's email address.

Contact Phone*

Enter the Contact Employee's Phone Number.

Other Reason

If the emergency is other, please provide explanation.

Event*

Enter the name of the Natural Disaster event if applicable. If no associated name just enter event by Type of Natural Disaster (ie: Hurricane Fran, or Winter Storm )

Additional Information

Begin Date*

Enter the first date of the closing.

End Date*

Work Hours Missed*

Enter the number of work hours affected by this Emergency Closing. Ex: If your work site is a Mon-Fri 8 to 5 operation and you were closed 2 complete business days then you would report 16 hours. If you are a 24 hour operation and your facility was closed an entire 2 days, you would report 48 hours.

Evacuation Order

Was this closing due to a mandatory evacuation order? If so, please check box, otherwise leave box blank.

Ordered by*

Emergency Employees*

Enter number of Emergency Employees affected by closing. EMERGENCY EMPLOYEE DEFINED: Emergency employees are employees who are required to work during emergency conditions because their positions have been designated by their agency head or designee as necessary in response to a specific emergency situation in compliance with the agency’s emergency response plan.

Non-Emergency Employees*

Enter the number of Non-Emergency Employees affected by the closing.

Once completed, check the "Send me a copy of my responses" box and submit the form. NOTE: Suspension of non-mandatory operations due to adverse weather which causes hazardous travel conditions (such as accumulation of snow or ice on roads, parking lots and sidewalks) does not qualify as an emergency closing. Non-emergency employees who are impacted by an emergency closing or evacuation who are not required to work at an alternate site shall not be required to charge leave or make up the time. The state shall provide paid time off for those employees.

Agency Head Approval

I certify that the agency head is aware and has approved this closing.

Yes

Attach Files

Attach any of the necessary supplemental information: * Public Information news release * Evacuation Orders * Emergency Information * Any applicable documentation

File Attachments*

Drag and drop files here or

Send me a copy of my responses

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