Information

  • Document No.

  • Department/ Site

  • Conducted on

  • Prepared by

  • Fire Drill Evaluation 12/16 (75%) = Pass Drills that score below a 75% requires immediate follow-up.

Signatures

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

  • Add signature

Department Questions

  • If there is a fire in your department, what are your response procedures? (RACE/PASS)

  • If the fire is in an adjacent department, what are your response procedures? (prepare for influx of patients/visitors/ TMs- clear hallway, close patient doors, etc.)

  • What does RACE Stand for? (rescue-alarm-contain-extinguish/evacuate)

  • What does PASS stand for? (pull-aim-squeeze-sweep)

  • Where is your nearest fire extinguisher?

  • Where is your nearest pull station?

  • Who has the authority to shut off oxygen? ( NS- nurse in charge of the department- Respiratory- FD)

Evacuation Team Questions

  • Who has the authority to shut off oxygen? ( NS- nurse in charge of the department- Respiratory- FD)

  • What is the duty of the evacuation team? (aid in evacuation procedures)

  • Did the Nursing Supervisor bring the grand master key?

  • Where should patients and guests be evacuated? (horizontal, into adjacent smoke compartment)

Drill Information

  • Was Code Red and correct location paged 3 times?

  • Did the evacuation team response within 1 minute?

  • Were fire alarm devices functioning properly in the drill area?

  • Did fire doors close and latch in drill area?

  • Did the monitoring company receive the alarm signal? What time?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.