Northside Hospital Forsyth

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location:

• Time Drill Begin:

• Time Drill End:

• Time Fire Dept. Notified:

• Time Alarm Company Notified:

• Engineer On-Duty:

• Drill Conducted By:

• Number of Smoke Compartments Observed:

Staff Procedures

• Did Staff pull the fire alarm pullstation?

  Yes

  No

  N/A

• Did Staff know the emergency number to call? (SS-8911)(F-54321)(C-250)

  Yes

  No

  N/A

• Did Staff close room doors promptly?

  Yes

  No

  N/A

• Does Staff know the code for fire?

  Yes

  No

  N/A

• Did Staff bring fire extinguishers to the Code Red location?

  Yes

  No

  N/A

• Could Staff explain how to use a fire extinguisher or P-A-S-S?

  Yes

  No

  N/A

• Did Staff know the meaning of R-A-C-E?

  Yes

  No

  N/A

• Was Staff able to point out the location of the Medical Gas Zone valves?

  Yes

  No

  N/A

• Did Staff know who was authorized to shut off Medical Gas Zone valves?

  Yes

  No

  N/A

• Were evacuation corridors cleared of carts and other temporary obstructions?

  Yes

  No

  N/A

• Did Staff know where and how to move patients away from fire location?

  Yes

  No

  N/A

• Was Staff able to locate to locate their written fire evacuation/relocation plan and the evacuation diagram?

  Yes

  No

  N/A

• Was Staff able to locate Emergency Preparedness Manual and the Emergency Conditions Matrix?

  Yes

  No

  N/A

Fire Team Response

• Did PBX page Code Red and location clearly?

  Yes

  No

  N/A

• Did Fire Team respond promptly?

  Yes

  No

  N/A

• Did Fire Team respond with fire extinguishers?

  Yes

  No

  N/A

• Did Security Officer bring fire extinguisher?

  Yes

  No

  N/A

• Did Engineering know location of Medical Gas Zone valves?

  Yes

  No

  N/A

• Did Engineering know location of electrical panels?

  Yes

  No

  N/A

• Was the Fire Department notified by the alarm company?

  Yes

  No

  N/A

Life Safety System

• Did the pull station activate the Life Safety System?

  Yes

  No

  N/A

• Did all alarms and strobes function?

  Yes

  No

  N/A

• Could the overhead page for Code Red be heard?

  Yes

  No

  N/A

• Did all fire/smoke compartment doors automatically close?

  Yes

  No

  N/A

• Did the Life Safety system reset after alarm acknowledgement?

  Yes

  No

  N/A

• Remarks: