SCSS Fire and Evacuation Exercise Record

• Document No.

• Service User/s

• Site Address

• Conducted on

  Date

• Prepared by

• Add signature

  Sign

• Staff on shift, position & role during exercise:

• Resident name:

• Observed response/effect on person:

• Exercise scenario:

Sequence of events

• Was the alarm activated?

  Yes

  No

  N/A

• Did the staff respond?

  Yes

  No

  N/A

• Did the staff verify the emergency?

  Yes

  No

  N/A

• Were the emergency services notified?

  Yes

  No

  N/A

• Did staff check all areas?

  Yes

  No

  N/A

• Did everyone evacuate to the Assembly Area?

  Yes

  No

  N/A

• Was everyone accounted for?

  Yes

  No

  N/A

• Was a situation report given to emergency services?

  Yes

  No

  N/A

• Was the exercise completed?

  Yes

  No

  N/A

Emergency Response Checklist

• When emergency started were all occupants alerted?

  Yes

  No

  N/A

• Was the alarm activated?

  Yes

  No

  N/A

• Did staff follow proper procedures for scenario?

  Yes

  No

  N/A

• Was emergency confined to area of origin?

  Yes

  No

  N/A

• Were emergency services called promptly?

  Yes

  No

  N/A

• Were all areas of the house searched?

  Yes

  No

  N/A

• Did staff wear emergency identification?

  Yes

  No

  N/A

• Did occupants evacuate methodically?

  Yes

  No

  N/A

• Were mobility impaired persons evacuated?

  Yes

  No

  N/A

• Did anyone refuse to participate or follow instruction?

  Yes

  No

  N/A

• Was a designated evacuation route taken?

  Yes

  No

  N/A

• If not, was the most appropriate evacuation route taken?

  Yes

  No

  N/A

• Did all people go to and stay at the Assembly Area?

  Yes

  No

  N/A

• Were all people accounted for?

  Yes

  No

  N/A

• Did anyone re-enter the building before the all-clear?

  Yes

  No

  N/A

• List names:

• Were emergency services liaised with?

  Yes

  No

  N/A

• Was the correct information given to emergency services?

  Yes

  No

  N/A

Debrief

• Did you come across any difficulties during the exercise?

  Yes

  No

  N/A

• List any difficulties found during exercise:

• Suggested actions: