Stay Put Policy Assessor RPEEP Form

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This form is designed to create a Residential Personal Emergency Evacuation Plan for you and your household. Its purpose is to make sure you, and anyone living in your flat, have the right support to stay safe in the event of a fire.

The plan will help identify any additional needs you may have, such as mobility, vision, hearing, or health concerns, and agree on clear steps for how you will be supported to follow the building’s fire safety Stay Put policy.

The questions may cover things such as how you and anyone living in your flat would notice an alarm, move around in an emergency, whether English is your first language, or if you use any equipment or support to help you day-to-day.

This helps ensure that the fire safety plan is personalised to you and anyone living in your flat.

Your answers will be treated as confidential. The information you provide will only be shared with those who need it to keep you safe, such as the building manager, Housing Provider, or emergency services if required. It will not be shared for any other purpose and will be stored in line with data protection requirements.

Together with the assessor, you will use this form to agree on practical steps and record a clear evacuation statement so that you, your household, and those supporting you know exactly what to do in an emergency.

STAY PUT POLICY Resident PEEP Assessor Form

Assessors please use this form to fill out during the residential PEEP assessment.

Resident(s) and Property Information

Resident(s) Name(s)(Required)

Email Address(Required)

This is where we will send a PDF of our conversation today once the housing provider has received a copy.

Flat Number(Required)

Building Name and Address(Required)

Number of Residents Living in Household(Required)

Today's Date of Assessment(Required)

Name of TEAM Safety Services' Assessor(Required)

First

Resident(s) Communication Abilities

Are all residents in this household able to understand emergency instructions?(Required)

Yes

Sometimes

One or more residents may need support

Do any residents in this household require communication support (e.g., interpreter or translated materials)?(Required)

Yes

If yes, please specify what language or interpreter support is needed

Do any residents have cognitive or memory concerns that may affect their understanding or response to fire alarms?(Required)

Yes

If yes, please provide further details or concerns

Assessor's Controls and Recommendations for Communication Support(Required)

Resident(s) Physical Mobility

Resident(s) Mobility Status(Required)

All residents are fully mobile

One or more residents uses a walking aid

One or more residents are frail or have a history of falls

One or more residents uses a wheelchair (manual)

One or more residents uses a wheelchair (electric)

One or more residents are bed/chair-bound

One or more residents have very limited mobility

Other

Can the resident(s) self-evacuate without help?(Required)

Yes

No, one or more residents may need assistance

Assessor's Controls and Recommendations for Mobility Support(Required)

Resident(s) Sensory Abilities

Do any residents in this household have any hearing loss or difficulties that might affect how they notice alarms or emergency instructions?(Required)

Partial

Profound

If yes, do the resident(s) use any hearing support?(Required)

Hearing aid

Cochlear implant

Visual alert system

Other

Not Applicable

If other, please specify what hearing support they use

Do any residents in this household have any vision loss or difficulties that might affect how they see alarms, signs, or emergency instructions?(Required)

Partial

Profound

If yes, do the resident(s) use any vision support or assistive devices?(Required)

Glasses or magnifiers

Walking cane

Guide dog

Noise alert system

Other

Not Applicable

If other, please specify what vision support they use

Assessor's Controls and Recommendations for Sensory Support(Required)

Resident(s) Health, Medication and Behaviour

Do any residents in this household have medical conditions that could impair their ability to respond to a fire or evacuate?(Required)

Maybe

Yes

Yes, but the resident didn’t want to specify

If maybe or yes, please specify what medical conditions they have

Do any residents in this household use emollient creams that are petroleum or paraffin-based?(Required)

Yes

Do any residents in this household require medical equipment (e.g. oxygen cylinders, ventilator, air pressure mattress)?(Required)

Yes

Yes, but the resident didn’t want to specify

If yes, please specify what medical equipment they use

Do any residents in this household have any mental health conditions that could affect their response to an emergency?(Required)

Anxiety, Depression, Post-Traumatic Stress Disorder, Obsessive-Compulsive Disorder

Schizophrenia/Psychotic Disorders, Bipolar

Autism, Non-Verbal or Mute

Alcohol dependency or misuse of drugs

Yes, but the resident didn’t want to specify

Other

If other, please specify what mental health condition or concern

Do any residents in this household have any cognitive condition that could affect their response to an emergency?(Required)

Dementia or Alzheimer’s Disease

Learning Disabilities

Brain Injury

Yes, but the resident didn’t want to specify

Other

If other, please specify what cognitive condition

Do any residents in this household smoke or vape?(Required)

Yes – Smokes cigarettes inside

Yes – Smokes cigarettes outside

Yes – Smokes vapes inside

Yes – Smokes vapes outside

Are there any items, furniture, belongings, or clutter in the home that could block escape routes or make evacuation more difficult?(Required)

There is some, but minor, clutter

Yes

Are internal doors left open at night?(Required)

Sometimes

Yes

Assessor's Controls and Recommendations for Health, Medication and Behavioural Support(Required)

Flat Fire Risks

Are there any fire risk factors in the home?(Required)

Assessor's Controls and Recommendations for Flat Safety Support(Required)

Support and Assistance

Are any residents in this household supported by carers or family members?(Required)

Yes

If a resident is cared for by a family member, please provide the family member's name and relationship to resident

Is any resident in this household part of a buddy or support system in the building?(Required)

Yes

If yes, please provide further details

Assessor's Controls and Recommendations for Assistance Support(Required)

Alarms and Evacuation

Has a carbon monoxide alarm been installed in any room where gas or solid fuels are used?(Required)

Yes

If yes, please specify in which room(s) the carbon monoxide alarm(s) are installed

Is there adequate fire detection and warning within the property?

Yes

If no, please specify what additional detection is required

Can all residents in this household hear and/or see the fire alarm system?(Required)

Yes

Assessor showed and tested their flat fire alarm as example

Do all residents in this household understand what to do when the alarm sounds?(Required)

Yes

Assessor shared information on what to do with the resident/s

Are all residents in this household aware of the building’s evacuation strategy?(Required)

Yes

Assessor shared the evacuation strategy with the resident/s

Can all residents in this household safely evacuate?(Required)

Yes

No, one or more residents can't safely evacaute

If no, please specify what barriers the resident(s) face when safely evacuating

Assessor's Controls and Recommendations for Alarm and Evacuation Support(Required)

Evacuation Statement

This evacuation plan has been developed in partnership between the assessor and the resident(s) to identify the safest and most practical way to respond in the event of a fire or emergency. It sets out the agreed arrangements, support needs, and responsibilities to ensure the resident(s) can be alerted promptly and evacuated safely. This evacuation statement provides clear instructions for the resident(s) within this domestic dwelling.

What “Stay Put” Means

Stay Put is the agreed safety policy in many purpose-built blocks of flats. If there is a fire elsewhere in the building but not in your flat, you are usually safer staying inside your home with the door closed, rather than trying to leave through smoke-filled corridors or stairways. While you Stay Put, you must: Call 999 immediately and tell the fire service where you are. Close doors and windows to keep smoke out. Wait for firefighters to arrive and follow their instructions. If smoke, heat, or fire does affect your flat, you should leave immediately using your agreed escape route and personalised evacuation plan.

What This Means

If a fire starts or spreads to your home, it is no longer safe to Stay Put. You should follow the steps set out in this personal evacuation plan, which has been created based on your household's needs and the safest routes available. This may include leaving immediately using your agreed escape route, using any mobility aids, support, or assistance identified in this plan, and going directly to your designated safe location. You must call 999 once you are safe and tell the fire service. Do not stop to collect belongings or re-enter the flat once you have evacuated.

Evacuation

In the event of an immediate fire, all residents within this flat must evacuate to a place of reasonable or ultimate safety. This will be achieved by:

Method of Evacuation

Such as arranging a Buddy System, evacuation chair, or supported evacuation with assistance from [name/role]

Alarm and Alert Arrangements

Method(s) of alerting resident(s), such as a visual alert system (e.g. flashing beacon)

Assistance Required

Type of support agreed upon, such as physical assistance (e.g. carrying equipment), communication support (e.g. simplified instructions) and medical equipment (e.g. mobility device)

Assembly / Safe Location

The designated safe location outside the building and an alternative safe location (if the primary route is blocked)

Additional Notes

Any other relevant information, e.g. barriers identified, agreed review dates, additional measures required

Summary and Recommendations

What are the main fire risks identified?(Required)

What are the recommended adjustments or controls?(Required)

What is the recommended evacuation support strategy?(Required)

Any additional notes or comments

What To Do Next

Thank you for completing this fire safety assessment with your assessor. Together, you’ve identified the best way for you (and anyone else in your home) to stay safe if a fire occurs. Your evacuation plan is now agreed, but there are also some simple steps you can take to reduce risks in your flat and make sure your plan is successful: Check your alarms regularly – if you can, test smoke and heat alarms once a week to make sure they’re working. Keep escape routes clear – don’t let hallways, doors, or windows become blocked by furniture or belongings. Mobility aids and any methods of calling for help should always be kept close to hand. Review your plan often – if your health, mobility, or living situation changes, please let your Housing Provider know so that we can update your evacuation plan. Know who to call – in any emergency, dial 999 immediately and follow the instructions from the fire service.

Flat Fire Safety Advice

Fires can start quickly and unexpectedly, but small actions at home can make a big difference to your safety. In the kitchen: never leave cooking unattended, keep tea towels and flammable items away from hobs and heat. Electrical safety: avoid overloading sockets, unplug appliances when not in use, and replace damaged cables or plugs. Smoking safety: It is safer not to smoke, but anyone who does should try to smoke outside and always make sure cigarettes are put out properly. Never smoke in bed. Candle safety: Candles, tea lights and incense burners should only be placed in stable, heat-resistant holders. Keep these items or any other type of naked flame well away from curtains, furniture and clothes. Heaters: Sit at least one metre away from heaters and keep them well away from anything that can catch alight. Night-time routine: before bed, switch off appliances, close internal doors to slow the spread of smoke, and make sure escape routes are clear. During an alarm: If the fire is not in your flat and you are not directly affected by smoke or heat, stay inside your home with the front door closed. Call 999 to report the alarm and follow the fire service’s instructions. If the fire is in your flat or smoke/heat is affecting you, follow your agreed evacuation plan laid out in this form. Do not use lifts, do not go back for belongings, and move calmly to the place of safety identified in your plan. If escape isn’t possible, move everyone to the room furthest from the fire, close the door, and block any gaps with soft materials or fabric. Stay low to the floor if smoke enters. If it’s safe, go to a window for fresh air, call 999, and tell the fire service where you are. Wave a torch, phone, or cloth at the window to help firefighters find you.

Review Schedule

Recommended next review date:(Required)