To:       (NAME)                 (DATE)

Fr:        (NAME)

Re:       Instructions on Completing the Actions Taken/Lessons Learned Log

Background and Timing

This log documents your organization’s response to an emergency. For example, “On (date and time), an incident occurred which disrupted operations. Specifically, (describe the event. For example, “a fire started in the computer room, or a ceiling pipe burst.”).

Actions Taken

Additionally, specify what happened. For example, “the fire department was called” or “the Emergency Response Team (ERT) activated parts of the Emergency Action Plan.”

For example, “The incident resulted in an order to (e.g., “evacuate the immediate area.”).”

Operating Impact

Summarize the relevant impact and subsequent actions. For example, if operations were temporarily transferred to another location, indicate the time and effect on operations. If additional personnel were needed to cover operations, describe this and the financial implications, etc.

For each entry, note suggestions for improvements (under the Lessons Learned/Recommendations column). Not every incident must be matched with a recommendation. If the current procedure worked well, please indicate this as a validation of the current procedure.

Incident Description:
Date and time of incident:

MM/DD/YY   XX:XX AM/PM

Impact: Lessons Learned/Recommendations
[Action taken by ERT] [Observation and Comments] [Specific Recommendations/Lessons Learned]

Other Comments:

Use this space to document any other aspects of the event that merit recording. Feel free to append photographs or video records to help document events or point the way to improving your organization’s response.

If actions taken addressed requirements of various regulations or stated governance procedures, note these facts in the spaces provided below:

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

Attestation

                                                                                                                                                                              
Signature                                                                                               Date

                                                                                               

Printed Name