Fire or Drill Report Form

FIRE / DRILL REPORT
Type: o Actual Fire o Drill o Other Fire Alarm Total Staff Participating: ________
Date: ____/____/____ Time: _________ oam opm Shift: o1 o2 o3
Building Number: ______ Division:
Describe Fire / Drill Scenario:
People Involved: oUnit/Area Staff oPatients oSecurity oMaintenance oVendors
oHousekeeping oNutrition Services oVisitors oStudents oVolunteers oOthers
Critique Actions Taken:
Yes No N/A (Write a brief description in box below for any “No” answers)
Call for HELP
Rescue anyone in immediate danger
Yell CODE RED
Pull fire alarm
Dial 6 or 4911
Say “There is a fire / drill in Bldg. ____, Unit ____”, describe extent of fire & actions being taken,
& state your name
Confine fire compartment (close doors, windows, openings, etc.)
Extinguish
Unlock patient doors
Line up patients at exit furthest from smoke/fire
Evacuation to point of safety
Coordination with HP & Fire Dept
Evacuation times Time Time Elapsed
Time of alarm: _____
Time ready at staging point: _____ ____ min
Time evacuated to safety point: _____ + ____ min
Total time to evacuate: = ____ min
Follow Up:
Yes No N/A (Write a brief description in box below for any “No” answers)
Patients returned to secure living quarters
Date: ___/___/___ Time: _____ oam opm
Smoke vented from building
Maintenance resets alarms
Fire extinguishers replaced
Damaged material removed and/or replaced
Other
Please print:
Building Fire Warden: Div/Dept Fire Marshall:
Person Completing Report: Ward: Phone ext
Distribution: Division Fire Marshall (Photocopy); original to Risk Management (within 5 days of fire or drill) FORM 7964 (9/02)
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Fire or Drill Report Form PDF

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