Northside Hospital Off-site Fire drill Evaluation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Staff Procedures

• 1. Did staff pull the pull station?

  Yes

  No

  N/A

• 2. Did staff know the emergency number to call?

  Yes

  No

  N/A

• 3. Did staff close doors promptly?

  Yes

  No

  N/A

• 4. Does staff know where the fire extinguisher(s) are located?

  Yes

  No

  N/A

• 5. Could staff explain how to use a fire extinguisher or P.A.S.S (Pull, Aim, Squeeze, Sweep).

  Yes

  No

  N/A

• 6. Did staff know the meaning of RACE? Rescue, Alarm, Contain, Extinguish.

  Yes

  No

  N/A

• 7. Was staff able to locate medical gas zone valves?

  Yes

  No

  N/A

• 8. Did staff know who is authorized to shut off medical gas zone valves? FRESH, Fire Chief, Respiratory Therapy, Engineering, Safety Officer, House Coordinator.

  Yes

  No

  N/A

• 9. We're evacuation corridors cleared of carts and or any other temporary obstructions?

  Yes

  No

  N/A

• 10. Did staff know where and how to move patients away from fire location?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 12. Was staff able to locate emergency preparedness manual and the emergency conditions matrix?

  Yes

  No

  N/A

Fire Response

• 13.

  Yes

  No

  N/A