Hospital Fire Drill

• Select date

  Date

• Department

• Department Type

  Patient Care Area

  Non-Patient Care Area

• Activation Location (please approximate location via drawing/photo)

  Drawing

• Departments Critiqued

• Adjacent -

• Above -

• Below -

• Activation Location Photo

  Media

• Evaluation Team

FA - FIRE AREA RESPONSE CRITIQUE

• FA01 - Did staff rescue those in immediate danger?

  Yes

  No

  N/A

• FA02 - Did staff alerts others in/around the fire area?

  Yes

  No

  N/A

• FA03 - Was the '555' call made appropriately?

  Yes

  No

  N/A

• FA04 - Did staff activate the fire alarm system?

  Yes

  No

  N/A

• FA05 - Did staff close patient room & corridor doors?

  Yes

  No

  N/A

• FA06 - Were corridors free of obstructions for evacuation?

  Yes

  No

  N/A

• FA07 - Did staff keep calm and guide patients and visitors?

  Yes

  No

  N/A

• FA08 - Did someone take charge of the situation?

  Yes

  No

  N/A

• FA09 - Were fire extinguishers deployed?

  Yes

  No

  N/A

• FA10 - Did non-area staff respond timely to assist?

  Yes

  No

  N/A

FB - NON-FIRE AREA RESPONSE CRITIQUE

• FB01 - Did someone take charge of the situation?

  Yes

  No

  N/A

• FB02 - Were all doors closed in corridor?

  Yes

  No

  N/A

• FB03 - Were corridors cleared of obstructions?

  Yes

  No

  N/A

• FB04 - Were patients and visitors kept in rooms?

  Yes

  No

  N/A

• FB05 - Were patients and visitors kept informed?

  Yes

  No

  N/A

• FB06 - Did staff respond to the fire area to assist?

  Yes

  No

  N/A

FC - STAFF KNOWLEDGE

• FC01 - Are staff familiar with RACE?<br>Race Activate Contain Evacuate

  Yes

  No

  N/A

• FC02 - Are staff familiar with PASS?<br>Pull the pin Aim. Aim the nozzle. Squeeze the handle. Sweep from side to side.

  Yes

  No

  N/A

• FC03 - Do staff know the location of the nearest fire alarm pull station?

  Yes

  No

  N/A

• FC04 - Do staff know the location of the departments portable fire extinguishers?

  Yes

  No

  N/A

• FC05 - Do staff know the medical gas shutoff valve location and who is authorized to shut down piped gasses to the unit?

  Yes

  No

  N/A

• FC06 - Do staff know the adjacent smoke compartment?

  Yes

  No

  N/A

FD - FIRE SYSTEM CRITIQUE

• FD01 - Was the alarm audible throughout the area?

  Yes

  No

  N/A

• FC02 - Was the alarm visible throughout the area?

  Yes

  No

  N/A

• FD03 - Did all fire system features work appropriately? Magnetic door holds released, heat, smoke, and strobes all function, and no obvious sprinkler system concerns in area?

  Yes

  No

  N/A

FE - EVACUATION CRITIQUE

• FE01 - Do staff know the department evacuation plan?

  Yes

  No

  N/A

• FE02 - Do staff know the appropriate evacuation destination for their patients?

  Yes

  No

  N/A

• FE03 - Do staff know the evacuation routes / emergency egress routes from their department?

  Yes

  No

  N/A

• FE04 - Do staff know the difference between horizontal and vertical evacuation?

  Yes

  No

  N/A

• FE05 - Are staff familiar with appropriate evacuation methods for their patient population?

  Yes

  No

  N/A

• FE06 - Is evacuation equipment available and appropriate for patient population?

  Yes

  No

  N/A

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Please sign your name and position

  Sign

• Include photo if appropriate (optional)

  Media