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

• Did staff demonstrate knowledge of the use and function of the fire alarm system? If applicable?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was this # dialed?

  Yes

  No

  N/A

• Identified self and area?

  Yes

  No

  N/A

• Gave exact location of fire?

  Yes

  No

  N/A

• Did staff evacuate any patients from the immediate danger zone?

  Yes

  No

  N/A

• Was the facility totally evacuated?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Were there self-activating fire doors?

  Yes

  No

  N/A

• If so, did they close correctly?

  Yes

  No

  N/A

• Did staff close any doors manually to contain the fire ?

  Yes

  No

  N/A

• Did staff know the location of the nearest fire extinguisher?

  Yes

  No

  N/A

• Did staff activate a fire extinguisher?

  Yes

  No

  N/A

• Knew the PASS procedure of a fire extinguisher?

  Yes

  No

  N/A

• Knew the RACE procedure?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Knew the procedure to prepare for evacuation?

  Yes

  No

  N/A

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

  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