I don't have a template you're looking for, but if you go to
http://www.caa.co.uk/docs/33/CAP676.PDF you can download the UK CAP676. It explains how to design Emergency and Abnormal Checklists including the Human Factor principles involved. I have used it in the past to make just A4 normal checklists before and found it a great resource. I hope this helps. Goodluck!