Fillable Printable Fire Drill Report Form - Texas
Fillable Printable Fire Drill Report Form - Texas
Fire Drill Report Form - Texas
Texas Department of Aging
and Disability Services
Form 4719
September 2013-E
Fire Drill Report
Note: Notify the fire department before conducting the drill if the fire alarm signal is automatically transmitted to the fire department or to a
monitoring company.
Complete this section before conducting the drill. For each question, check ALL the answers that apply.
1. Simulated Situation
Fire Smoke Other (specify):
2. Location
Kitchen
Dining Lobby Office Bedroom Other:
3. Type of Fire
Bed Wastebasket
Kitchen Range
Laundry
Other:
4. Extent of Fire
Large
Small Explosion Electrical Paper Wood Controllable Other:
5. Extent of Smoke
Noxious
Whole Room Corridor
Heavy
Light
Smoldering
Other:
6. Exits Used in Relation to Simulated Situations
Front Door
Back Door Side Door Garage Door Window Other:
7. Rally Point Used (Fill in the blank. For example, in front of neighbor Smith’s house, street sign, etc.)
Complete this section after conducting the drill. Explain any “No” answer in the Comments/Problems section below.
1. Did the staff use proper judgment? .................................................................................................................
Yes No
2. What action(s) were taken during the fire drill?
3. Was the fire department called?.....................................................................................................................
Yes No
4. What time was the fire department called?
a.m.
p.m.
5. Were residents in halls removed to an area of safety? ........................................................................................
Yes No
6. Were all halls, corridors and other means of egress maintained clear and free of obstructions?...................................
Yes No
7. Were all corridor doors closed?......................................................................................................................
Yes No
8. Who responded to the fire drill and with what equipment?
9. Did the staff monitor the exits?.......................................................................................................................
Yes No
10. Was the building evacuated?.........................................................................................................................
Yes No
11. Did facility staff or the fire department extinguish any fire?...................................................................................
Yes No
12. Who sounded the "all clear" and at what time?
a.m. p.m.
13. Was the emergency plan executed correctly? ...................................................................................................
Yes No
14. Did the staff carry out their responsibilities?......................................................................................................
Yes No
15. Did the staff in different areas or wings: (Check all that apply and describe any problems in the Comments/Problems section below.)
Hear the fire alarm?
Respond promptly to the fire alarm?
Follow procedures calmly, smoothly and efficiently?
Follow proper procedures?
Return to their proper stations?
Stand by until "all clear" given?
Hear the "all clear" announcement?
Comments/Problems:
Names of Participants:
Report Completed By:
Title: Date Drill Conducted: Time:
Shift:
Note: Keep this completed form in the facility and present it to the surveyor at the time of the inspection.
