• Audit Title

  • Clinic / Site

  • Conducted on

  • Prepared by

  • Clinic / Site Manager-Supervisor

Site Information

  • Shift

  • Quarter

Drill Assessment

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

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

  • Was this # dialed?

  • Identified self and area?

  • Gave exact location of fire?

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

  • Was the facility totally evacuated?

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

  • Were there self-activating fire doors?

  • If so, did they close correctly?

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

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

  • Did staff activate a fire extinguisher?

  • Knew the PASS procedure of a fire extinguisher?

  • Knew the RACE procedure?

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

  • Knew the procedure to prepare for evacuation?

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


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

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.