MMH Fire Drill Evaluation

• Document No.

• Department/ Site

• Conducted on

  Date

• Prepared by

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

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Department Questions

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• 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.)

  Safe

  At Risk

  N/A

• Where is your nearest fire extinguisher?

  Safe

  At Risk

  N/A

• Where is your nearest pull station?

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

Evacuation Team Questions

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Did the Nursing Supervisor bring the grand master key?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

Drill Information

• Was Code Red and correct location paged 3 times?

  Yes

  No

  N/A

• Did the evacuation team response within 1 minute?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Did fire doors close and latch in drill area?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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