POLICY & PROCEDURE – 8501 EXCELSIOR
10/04 REV 2/16
Other _8501 Excelsior Building__
Title: 8501 Excelsior Fire Response
To protect the safety of visitors, staff and physical environment by ensuring that staff are
prepared to respond in the event of a fire situation, and that appropriate safety measures are
implemented to prevent such situations.
Fire is one of the most serious safety issues facing the UW Health office building. All staff
should be familiar with response procedures to ensure the safety of visitors, staff and physical
environment in the event of a fire. The UW Health Office Building Management Team is
responsible for providing up-to-date response procedures, conducting ongoing safety training for
staff, and implementing annual fire drills and other prevention measures. UW Health Safety and
Hazard Control Manager ensures that plans are coordinated with UW Health and the Madison
Fire Drill Evaluation Form (available on U-Connect)
A. Fire Response
1. Immediate Response: R-A-C-E
Any staff member who discovers smoke or fire should implement the
R escue patients and/or staff from immediate threat of smoke or fire. Because
smoke and fire spread rapidly, patients, visitors and staff should be immediately
evacuated from the room where the fire is occurring and the door closed behind
A lert the Fire Department by pulling the fire alarm and calling 911. The fire
alarm automatically notifies the Madison Fire Department,.
C onfine the smoke or fire by closing all doors
E vacuate the building as quickly as possible
2. If You Smell Smoke
If a staff member smells smoke or burning in the apparent absence of fire -- it
should be reported to any member of the UW Health Office Building
Management Team for further investigation, with the following information:
location of the smoke
a phone number at the site
what the smoke smells like (plastic, paper, etc.)
the staff member's name
3. If the Fire Alarm sounds:
When the fire alarm sounds, all persons in the building must evacuate
immediately. Employees must advise any visitors they are with or they
encounter upon exiting the building to accompany them.
NOTE: Staff on the upper floors must use the stairs, not the elevator, for
exiting in response to an alarm.
Upon exiting the building, all staff must proceed to the rendezvous zone to which
they are assigned. Rendezvous zones are determined by the location of the
employee’s normal office or work station per the UW Health Office Building
4. Once outside the building:
a. Anyone with information regarding the location or nature of the fire
should immediately seek out a UW Health Office Building Management
Team member on-site and convey that information before proceeding to
his or her designated rendezvous zone.
b. Department supervisors are responsible for ensuring that all their staff
members exited the building safely and are at the rendezvous area.
b. Upon arrival, the Madison Fire Department (MFD) is in charge of the
fire scene. The building cannot be reentered until the MFD has stated that
it is safe to do so.
c. Once the MFD has given the “all clear”, administrative staff will convey
this to the rendezvous zones via the 8501 Excelsior Page List. All staff
must remain in their designated rendezvous zone until informed by MFD
personnel or administrative staff that it is safe to reenter the building.
d. If patients or visitors wish to leave the site, they may do so provided they
do not interfere with the movement of fire trucks and MFD personnel.
The UW Health Office Building Management Team will evaluate and summarize
the fire response using the Fire Drill Evaluation Form located on U-Connect. A
copy will be sent to the UW Health Safety Program Director. This written
evaluation will become a part of the Fire Drill and Response Record.
B. Fire Drills
Fire drills will be conducted annually. Their purpose is to ensure that employees know
what to do in case of a fire, and to monitor and evaluate the effectiveness of the response.
Because fire drills prepare staff for a real emergency, they are conducted as if a fire were
actually happening. Staff should respond accordingly.
The UW Health Office Building Management Team will randomly check areas
throughout the building during the drills to evaluate the timeliness of the response, proper
activation of building systems, and appropriate execution of responsibilities. An “All
Clear” page will be sent out to the Excelsior Emergency Page List to communicate it is
okay to return to work. Following the drill, administrative staff observers will complete
Fire Drill Evaluation Form.
Violation of this policy can lead to disciplinary action and/or termination.
VI. AUTHOR: 8501 Excelsior Drive Management
REVIEWER: UW Health Safety Program Director