Fillable Printable Fire or Drill Report Form
Fillable Printable Fire or Drill Report Form
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)
Fire Inspections
Check appropriate box
Item Yes No NA Reported Deficiency to:
Electrical
Receptacles in good repair
Grounded plugs
Extinguisher
Pressurized (in the green)
In place
Accessible (not blocked)
Access keys
Evacuation Plan
Displayed
Current
Exits
Clear/ unobstructed
Exit keys
Signs fully lit
Stairwell lights lit
Oxygen signs posted
Corridors clear
Emergency Lights, Flashlights
In place
Working / Operational
Fire Doors
Closing Properly
Unobstructed
Combustibles properly stored
Elevators sent down to the first floor
Fire drills test staff knowledge of:
1. Use and functioning of fire alarm systems (where
such alarms are available)
2. Transmission of alarms (where such alarms are
available)
3. Containment of smoke and fire
4. Transfer to areas of refuge
5. Fire extinguishment
6. Specific fire-response duties
7. Preparation for building evacuation
Please submit a work order for each deficiency.
FORM 7964 (9/02)
