Health and Safety Form - Emergency Response Plan

MM slash DD slash YYYY
MM slash DD slash YYYY
Group/Activity Leader

Trained First Aid Responders on-site

Name of Responder 1
Name of Responder 2
Name of Responder 3

Accessing Emergency Medical Assistance

Is emergency medical assistance available on-site?
On-site or nearby
Frequency and Call Sign
Emergency Position Indicating Radio Beacon


Police, Fire, Ambulance: 000 or 112 (in limited reception)

Poisons Information Centre: 131 126

Name of Additional Contact 1
Include any additional contacts specific for activity and/or site (eg. PWS on call ranger, land holder, closest medical facility)
Name of Additional Contact 2
Name of Additional Contact 3