Title Page
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Site
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Date and Time of Drill
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Weather
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Safety Coordinator
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Address/Location
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Number of staff attended
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All 3 shifts attended?
COMMUNICATION
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Method of Drill Activation
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Please specify
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Drill preannounced
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Fire department present for drill
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Alarm monitoring company notified
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Security notified
EVACUATION ASSESSMENT
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Evacuation routes posted
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Evacuation signs are in good condition
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Exits are clearly marked
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Exit signs are properly illuminated
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Exit doors operating properly
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Egress routes free of obstructions
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Egress routes properly lighted
FIRE ALARM SYSTEMS
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Fire alarms are working properly and clearly heard in all areas
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Alarm monitoring company received alert
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Electra-magnetic locks operated appropriately
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Public address system clearly heard in all areas
UTILITIES
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Electrical appliances were turned off
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Lights were turned off
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HVAC units were shut down
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Smoke detectors are in good condition
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Sprinklers are in good condition
EVACUATION
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All occupants participated and evacuated
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Restrooms were checked for occupants
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Evacuation was orderly
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Visitors escorted and accounted for
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Special needs persons accommodated
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Elevators were used during evacuation
FIRE CONTAINMENT
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Doors and windows closed
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Rooms checked prior to closing doors
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Doors left unlocked
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Fire extinguisher taken to location of fire
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Door hold-open devices operated appropiately
PLAN ASSESSMENT
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Evacuation performed according to plan
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Occupants met at designated meeting places according to the plan
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Designated meeting place(s) located at safe distance from building
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Fire drill/incident response team(s) responded according to plan
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Fire drill/incident response team(s) carried out assigned duties
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Fire department "mock" notified according to plan
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Elevators recalled to correct floor
COMPLETION
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All staff completed drill
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Alarm was audible?
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Correct evacuation and safety measures followed
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Safety Officer attended and approved?
EMPLOYEES ATTENDED NAME DATE TITLE PASSED YES NO RETEST
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1
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2
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3
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4
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5
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6
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7
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8
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9
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PROGRAM DIRECTOR SIGNATURE AND DATE
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NEXT TEST DUE DATE