Safety Fire / Evacuation Drill

• Audit Title

• Clinic / Site

• Conducted on

  Date

• Prepared by

• Clinic / Site Manager-Supervisor

Site Information

• Shift

  Day Shift

  Afternoon Shift

  Night Shift

• Quarter

  1st Quarter (Jan-Mar)

  2nd Quarter (Apr-Jun)

  3rd Quarter (Jul-Sep)

  4th Quarter (Oct-Dec)D

Drill Assessment

• 1. Did participanst of the fire drill zone staff demonstrate knowledge of the use and function of the fire alarm system?

  Yes

  No

  N/A

• 3. Do staff know the appropriate # to dial to report a fire in the facility?

  Yes

  No

  N/A

• 4. Was this # dialed?

  Yes

  No

  N/A

• 5. Identified self and area?

  Yes

  No

  N/A

• 6. Gave exact location of fire?

  Yes

  No

  N/A

• Did staff evacuate any patients from facility?

  Yes

  No

  N/A

• 7. Described nature and extent of fire?

  Yes

  No

  N/A

• 8. Did the participant demonstrate the knowledge of confining the area of fire?

  Yes

  No

  N/A

• 9. Closing Doors?

  Yes

  No

  N/A

• 10. Knew the location of the nearest fire extinguisher?

  Yes

  No

  N/A

• 11. Knew the PASS procedure of a fire extinguisher?

  Yes

  No

  N/A

• 12. Knew the RACE procedure?

  Yes

  No

  N/A

• 14. Knew the location of the O2 shut-off valve?

  Yes

  No

  N/A

• 15. Knew the procedure to prepare for evacuation?

  Yes

  No

  N/A

• 16. Did the staff demonstrate the knowledge of the fire drill announcement?

  Yes

  No

  N/A

• 17. Did the staff demonstrate knowledge of the location of the muster point?

  Yes

  No

  N/A

• 18. Any additional points of concern to be addressed?

  Yes

  No

  N/A

Scoring:

• Enter any comments along with score " Passed or Failed "

• Please enter your name then sign when assessment is completed.

  Sign