For CBHS use only

                                                                                                             Parent Agency:
                                                                                         Date submitted

                                     Site Specific Emergency Response Plan
                                                    Appendix A

Parent Agency:
Site Name:
Site Address:
Covered by this site specific plan
Cross Street:
Program(s) at this location:                 (add additional page if necessary)
Reporting Unit #:                            NAME:
Reporting Unit #:                            NAME:
Reporting Unit #:                            NAME:

Site Telephone:
Hours of Operation:
For Residential Services, list number of beds:

                                                                                                             Site Name:
Program Director(s)

Emergency Coordinator: (Name of person responsible for preparing, updating, and
       training regarding this Site Specific Plan):

       Date of last Emergency Plan Training:

       In the event of an emergency, the following individuals will serve as your site’s
       Incident Commander in respective order.

                        Name                    Title          Office             Home    Cell phone

          Submit this SSERP FORM to CBHS Administration:

                     Jean Mayeda
                     1380 Howard Street, 5th Floor
                     San Francisco, CA 94103

      A. Notification: Please list the contact information for the individual that would be
          contacted in the event of a facility related emergency (e.g., broken water pipe).


      The Emergency Coordinator will notify CBHS Administration in the event that the
      site is unable to maintain operations.

      B. Supplies and Equipment:

            a. Responsible party:

            b. Emergency Kit location:

            c. First Aid Kit location:

            d. Transistor Radio location:

            e. Flashlights locations:

            f. Site Vehicle Keys (employees and/or location kept on-site)

            g. Other emergency equipment and location:

      C. Evacuation:

         1. Evacuation maps are also posted at the following locations:

         2. Unless otherwise directed, all employees should immediately proceed to
         the following Evacuation Assembly Area:

         3. Evacuation Team Members:
        4. Check one of the following

               This site has a Building Fire Alarm. If the Building Alarm is activated, all
            employees, clients and visitors must evacuate.

                This site does not have a Building Fire Alarm. Describe the procedure
            for notification and evacuation:

 D.     Accounting for Employees: Attach Emergency Contact Sheet (Appendix C)

 E.     Hazardous Materials: List any hazardous materials and location

 In the event of a hazardous spill, contact the 911 and/or Bureau of Toxics, Health, and
 Safety Services at 252-3800.

F.      Building Safety: Please list location of the following:

     1. Emergency Lighting:

     2. Gas Valve (Main):

     3. Water Valve (Main):

     4. Steam/Boiler:

     5. Electrical Circuit Breaker:

     6. Tools:

     7. Fuel Pump (if applicable):

     8. Emergency Generator (if applicable):
G. Fire Clearance:

        Date of last Fire Clearance:
        Date of last Annual Maintenance of Fire Extinguishers (see tag):
        Date of last fire drill:
        Date of last earthquake drill:

   H. Medical Care:
   The closest medical facilities are listed below:

   Names                         Locations                           Phone No.

   I. Search and Rescue:
   List individual responsible to notify authorities of missing persons:

   Name                                        Title

   J. Building Security and Reoccupation:
   List individual responsible to lock doors following an evacuation:

   Name                                        Title

   K. Securing of Property:
   In the event that the building is no longer operable, list the parties responsible for
   ensuring the following:

        1. Securing medical records:
        2. Securing on-site emergency pharmaceutical supplies (if applicable):

   L.   Management of Minors:
   The procedure for handling minors not in the company of their parents/guardian
   is as follows (attach additional page if needed):

   M. Alternate Site:
   List the name and address (or intersection) an alternate site.
                APPENDIX B
               Evacuation Routes
(attach floor plan with emergency routes identified)

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