Department Emergency Action Plan

The Department Emergency Action Plan (DEAP) is required for every Medical Center Department as per Joint Commission EM Standard EM.01.01.01 to support the overall Emergency Operations Plan (EOP).  

The DEAP template is intended for both patient care and non-patient care departments and serves as a guideline. Departments should customize their DEAP to ensure all department needs are met.  If sections of this DEAP are not applicable to your department (e.g. inpatient vs. administrative office), please leave those areas blank or mark “N/A” as appropriate. 

Department Supervisors/Managers/Directors are responsible for:
- Annually reviewing/updating their DEAP and storing in the Environment of Care binder (under the yellow tab) or in the Department's Emergency binder.
- Ensuring all staff are familiar with the DEAP

To complete your DEAP, go to: 

User Guides:
- How do I Access the Department Emergency Action Plan Template
- How to Complete the Department Emergency Action Plan Template
- How to View/Edit Your Department Emergency Action Plan
- How do I Print my Department Emergency Action Plan

Important Links:
- New DEAP form link (for creating for first time)
- DEAP Edit Link (for editing or printing your DEAP and attachments)
- Hospital Smoke Compartments
- Staff Roster Template in Excel
- Evacuation Maps for Mission Bay
- Evacuation Maps for Parnassus and Mount Zion

DEAP Quality Rubric
A printable version of this rubric can be found here


Frequently Asked Questions

Q: How do I view my DEAP on the new Smartsheet platform?

A: See the User Guide: How to View/Edit Your Department Emergency Action Plan. If you have not completed your DEAP in Smartsheet, please view the User Guide: How to Complete the Department Emergency Action Plan Template


Q: How do I complete my unit's DEAP on the new Smartsheet platform?

A: See the User Guide: How to Complete the Department Emergency Action Plan Template. For additional guidance, feel welcome to attend a Drop-In DEAP Workshop, email [email protected] for more information. 


Q: When are the Drop-In DEAP Workshops and how do I register?

A: The Drop-In DEAP Workshops will be provided virtually via Zoom webinars. Participants do not need to register. For more information, email [email protected].

Drop-In DEAP Workshop Schedule:






12/18, 3:10 pm








12/28, 10:10 am 





Q: Why is there a score and grade for my DEAP?

A: In the new Smartsheet platform, DEAPs are now scored and graded for quality. To view the DEAP rubric, go here.


Q. What is a Floor Warden?
 A floor warden is an emergency role that is responsible for:

  • Assisting impacted staff, including those with disabilities and mobility impairments, during an evacuation. This would include directing them to Designated Waiting Areas or Areas of Refuge to wait for First Responder assistance.
  • Managing evacuation flow of occupants to ensure pathways or stairways are not blocked.
  • Assigning staff to call 9-1-1 emergency dispatch and activate an alarm.
  • Containing the fire by closing doors and conducting a quick check of each room.
  • Extinguishing the fire, if capable of doing so.
  • If the unit is in a hospital, this may involve evacuating to another smoke compartment.
  • If the unit is in a high-rise building, this may involve evacuating four stories down.
  • If an evacuation is required outside of the building, floor wardens will be responsible for accounting for all staff per the Department Emergency Callback & Personnel Roster found in the Department Emergency Action Plan.

Q: Who should be a Floor Warden for a Nursing Unit?
A: For Nursing Units, we recommend units designate their Unit Director and Assistant Unit Director as a Primary and Secondary Floor Warden. It is ok to leave the Tertiary Floor Warden information blank for now, more information to come on this. 

Q: How many Floor Wardens are expected for each unit/department?

A: The California Occupational Safety and Health Act (Cal/OSHA) requires 1 Floor Warden per 20 employees. UCSF requires 3 Floor Wardens per unit. This will allow coverage for up to 60 employees in addition to providing coverage for alternate shifts (ex. Day, Night, etc.) and time off.


Q. Why must UCSF have Floor Wardens?

A: In the event of an emergency, it is important to ensure staff, patients, visitors, and those with mobility issues can safely evacuate and are accounted for. Additionally, Floor Wardens are required for compliance with state and federal regulations (OSHA 29 CRF 1910.38; California Division of Occupational Safety & Health: Title 8 3220 Emergency Action Plan).


Q: What are the Training Requirements for Floor Wardens?

A: During their first year: Floor Warden should attend an online Learning Management System course titled “UCSF Floor Warden Training” (Duration: 45 minutes).
During the second year and beyond: Floor Wardens should attend a live Floor Warden Training Session (Duration: 50 minutes) to refresh their skills. The live training session is held two times a year at each UCSF Hospital Campus. 




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