Form Center

2. Date of Fire Drill
3. Time Drill Conducted
5. Shifts Involved

   1. 1st
   2. 2nd
   3. 3rd
6. Location of Fire
10. Alarm Performance
12. How/Why was the fire alarm sounded?
    -- Select One --Manual pullSprinkler systemPower outage
13. How was the drill initiated?
    -- Select One --Fire alarm pull stationSmoke alarm
15. List specific location of fire alarm pull station/smoke alarm used
17. What technique was used to represent/indicate fire (e.g., red cloth, sign, etc.)
19. Drill Type
    -- Select One --Audible alarmCoded/Silent alarm
21. Note: If alarm not audibly tested during drill, the alarm MUST be sounded the following morning.
23. Date Alarm Audibly Tested (if not tested during drill)
24. Did all staff hear the alarm?
    -- Select One --YesNo
26. Did all fire emergency equipment function properly (fire doors, smoke dampers, etc.)
    -- Select One --YesNo
28. Did auto dispatch notification function correctly
    -- Select One --YesNo
29. What time did dispatch receive alarm?
33. Personnel Performance (R.A.C.E.)
35. RESCUE
37. Were all the residents & visitors evacuated from the fire zone (i.e, were all areas secured)
    -- Select One --YesNo
38. Was there a proper/systematic search conducted
    -- Select One --YesNo
40. Did staff account for all residents
    -- Select One --YesNo
42. ALARM
44. Who activated the alarm?
45. Was the alarm properly activated
    -- Select One --YesNo
47. Did staff call the fire department (Drill Only)
    -- Select One --YesNo
48. Was the alarm reset (Coded Alarm)
    -- Select One --YesNo
50. CONTAINMENT
52. Did staff close resident room doors
    -- Select One --YesNo
53. Were corridor doors unobstructed
    -- Select One --YesNo
55. Did all corridor doors latch properly
    -- Select One --YesNo
57. EXTINGUISHMENT/EVACUATION
59. Were proper fire extinguishers taken to fire area
    -- Select One --YesNo
60. Did staff simulate using a fire extinguisher
    -- Select One --YesNo
62. Did staff stay with evacuation residents
    -- Select One --YesNo
63. If a "large" fire, were evacuation plans as outlined in "Fire Evacuation Procedure" followed:
    -- Select One --YesNoN/A
65. How long did it take to secure/evacuate all areas:
67. COMMENTS/SCENARIO
69. By typing your name and date below, you attest that the information contained herein is true and accurate.
71. Name of Person Supervising Drill
72. Title
73. Date
75. *A coded announcement may be used between 9PM & 6AM instead of audible alarms.
77. **If actual fire, use official state fire forms and report all details of the fire.
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79. 1. Receive an email copy of this form.
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