EmailMe Form - Facility Drill

Facility Drill
70-142
Rev. 06/15
FIRE DRILLS
Pathways, Inc. has developed a three-minute standard to safely evacuate consumers and staff in the event of a disaster. When a facility consistently meets this standard, you may wish to conduct drill using alternate exits to familiarize consumers and staff with them. Evacuation drills should be conducted with this standard in mind. If a facility demonstrates extremes (above or below the three-minute standard), please note why and what will be done to correct the situation in the “Additional Reportable Comments” section of the report.
Agency standards for non-residential facilities require at least one fire and bomb threat drill monthly. All residential facilities are required to conduct monthly fire and bomb threat drills.
Emergency Drill Annual Schedule
Jan: Fire, Evacuation
Feb: Fire, Natural Disaster (Tornado)
Mar: Fire, Utility Failure (Power Outage)
Apr: Fire, First Aid/Medical Emergency
May: Fire, Utility Failure (Water Leak)
Jun: Fire, Violent Situations (Including Robbery)
Jul: Fire, Hazardous Materials Spill/Infectious Control
Aug: Fire, Evacuation
Sep: Fire, Utility Failure (Gas Leak)
Oct: Fire, Natural Disaster (Earthquake)
Nov: Fire, Bomb Threat
Dec: Fire, First Aid/Medical Emergency
INSTRUCTIONS FOR COMPLETION OF DRILL REPORT
1. Enter the type of drill.
2. Enter date drill is conducted.
3. Enter the location and building code.
4. Enter the hour, minute, and seconds the evacuation started and ended, check whether time is AM or PM.
5. Enter the evacuation time in minutes and seconds.
6. Enter the number of people participating in drill.
7. Enter the name and professional number of staff who assisted with the evacuation and initial at right (applies in large facilities where staff is responsible for certain sections of the building and/or in situations where staff is assigned to help individuals who are physically or mentally challenged).
8. Enter reportable comments.
9. The Drill Coordinator signs and dates indicating that the drill occurred.
10. The Drill Reviewer signs and dates that all procedures and regulations were met.
11. The original EVACUATION DRILL form is kept in the Facility Manual and a copy is sent to the Quality Improvement Department.
Summary of Monthly Fire/Emergency Drill
Drill Date: *
MM / DD / YYYY HH : MM AM/PM
Location/Building Code: *
Program Type *
Type
Please check one: *
Fire
Bomb Threat
Utility Failures
Natural Disasters (e.g., tornado, earthquake, hurricane)
Medical Emergencies
Violent/Threatening Situations
Evacuation
Other
*
Scheduled Drill
Unscheduled Drill
Number of people involved in the drill:
Consumers: *
Staff: *
Visitors: *
Response
Staff properly inspected the property during the drill? *
Yes
No
All participants completed the drill and were accounted for? *
Yes
No
All participants met at the designated areas? *
Yes
No
Evacuation completed in an orderly manner? *
Yes
No
Any injuries reported during the drill *
Yes
No
If yes, a critical incident report was completed by whom:
Start Time: *
HH : MM AM/PM
End Time: *
HH : MM AM/PM
Minutes: *
Seconds: *
Drill Overview: *
Signature of staff member completing the drill:
Professional Number: *
Date: *
MM / DD / YYYY
Signature *
Clear
Signature of staff member reviewing the drill:
Professional Number: *
Date: *
MM / DD / YYYY
Signature *
Clear
Was this drill conducted by IDDS Staff? *
Yes
No
ADDITIONAL COMMENTS: TO BE COMPLETED BY IDDS STAFF ONLY
1. Checked restrooms, offices, etc.:
Yes
No
Staff Name:
First Last
2. Which exit was used:
Yes
No
Exit:
3. Verified all individuals were at designated location:
Yes
No
Staff Name:
First Last
4. Were there any individual(s) who refused to leave building:
Yes
No
Individual Name:
First Last
Individual Name:
First Last
Individual Name:
First Last
5. Discussed with individuals importance of exiting building:
Yes
No
Staff Name:
First Last
Please type your Supervisor/Director email below.
Supervisor/Director Email Address: *

Facility Drill

FIRE DRILLS

Emergency Drill Annual Schedule

INSTRUCTIONS FOR COMPLETION OF DRILL REPORT

Summary of Monthly Fire/Emergency Drill

Type

Number of people involved in the drill:

Response

Signature of staff member completing the drill:

Signature of staff member reviewing the drill:

ADDITIONAL COMMENTS: TO BE COMPLETED BY IDDS STAFF ONLY

Please type your Supervisor/Director email below.