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

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Department Questions

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

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

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

  • 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.)

  • 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?

  • Add Notes:

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