Office of Operations
21st Century Operations Using 21st Century Technologies

Evacuating Populations With Special Needs

Routes to Effective Evacuation Planning Primer Series

Annex 4: Sample Worksheet for Trip Times[107]

Driver Name:  
Total Passenger Count:  
Company/Agency Name:  
Company/Agency Contact Information:  


Departure Time Departure Location Arrival Time Shelter Location or Receiving Facility Passenger Name Staging Area Location Additional Pick-up Points
(if any)
Caregiver Name if Traveling Together List Any Service  Animal, Pet, or DME with Passenger Beginning & Ending Mileage Other
(Add in as necessary)

[107]   This is a sample worksheet; agencies should modify, add, and/or delete categories as necessary.