Fire Evacuation Drill Report - Connecticut Department Of Developmental Services

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CONNECTICUT DEPARTMENT OF DEVELOPMENTAL SERVICES
FIRE EVACUATION DRILL REPORT
FACILITY: ____________________________________________________ DATE: _____________________
AGENCY:______________________________________________________ QUARTER: _______ SHIFT: _______
TIME COMMENCED:________ AM / PM TIME COMPLETED:________ AM/ PM
TOTAL EVACUATION TIME:
SIMULATED EMERGENCY AND SITE: _________________________________________
_____________________________________________________________________________
_____________ MINUTES
CHECK & COMPLETE ONE TYPE OF DRILL CONDUCTED:
SURPRISE FIRE EVACUATION DRILL
SIMULATED DRILL/ RESIDENTS DO NOT PARTICIPATE
Must be “impractical e-score” or “health care” or have written approval from
Drills are used to evaluate what is likely to happen in a real emergency.
Local or State Fire Marshal
ACTUAL FIRE OR FIRE ALARM RESPONSE
.
In the event of an actual fire, fire alarm or perceived fire, a fire evacuation drill report should be completed.
CHECK & COMPLETE WHERE EVACUATED TO:
TO AN EXTERIOR POINT OF SAFETY
INTERIOR “POINTS OF SAFETY FOR USE IN “STAGED
EVACUATIONS”
_____________
EGRESS ROUTE /EXIT USED :__________
EXTERIOR MEETING PLACE: ________________________
MUST HAVE WRITTEN APPROVAL FROM AUTHORITY HAVING JURISDICTION
EGRESS ROUTE USED: _______________________________
NO EVACUATION (SIMULATED DRILLS ONLY)
INTERIOR POINT OF SAFETY:_________________________
HORIZONTAL EXITS/DEFEND IN PLACE FOR USE IN HEALTH CARE OCCUPANCIES ONLY
RESIDENT’S REACTION TO FIRE EVACUATION DRILL:
List all residents at home at the time of the drill, continue on separate page if necessary.
NOTE: ALL residents must participate, unless facility has a designated “Impractical” Evacuation score, or approved in writing by the A.H.J.
RESIDENTS WERE EVACUATED DURING THIS DRILL: (list names)
NOTE: Any identified occupant problems should be noted in this facility’s site specific fire safety plan
Independently
W/ Verbal assist and prompts
With total assistance
STAFF’S REACTION TO FIRE EVACUATION DRILL AND LIST ALL STAFF PRESENT AND PARTICIPATING:
(
Are Staff fully trained and did they respond appropriately?________________
Was Fire Safety Plan Followed?____________ Is it effective ? ____________
(Signatures Suggested)
PROBLEMS NOTED DURING THE EVACUATION DRILL:
NOTE: List below any problems identified during drill:
PROBLEM NOTED
CORRECTIVE ACTION
REVIEWED BY:
* PERSON IN CHARGE OF DRILL IS RESPONSIBLE TO FORWARD CONCERNS TO PROPER SUPERVISORS
MONTHLY FIRE SYSTEMS CHECKS (If required by your agency to be done at drill times)
ALL EMERGENCY LIGHTS CHECKED
FIRE ALARM TESTED AND FUNCTIONING
ALL EXITS CLEAR
ALL FIRE EXTINGUISHERS CHECKED
ALL FIRE DOORS CLOSED PROPERLY
EVACUATION PLAN UPDATED
EVACUATION DRILLS SHALL INCLUDE AT A MINIMUM:
1.
Notify FD or Alarm Company prior to Alarm activation
4.
Appropriate Evacuation to a Designated Safe Area of All
2.
Active the Alarm
<TIME STARTS>
Occupants
3.
Response of ALL staff and residents in the building (Vary
5.
An Accountability check for all Occupants
<TIME ENDS>
use of ALL EXITS - practice of use of windows not required)
6.
Assure alarm system is back in working order.
SEE BUILDING’S FIRE SAFETY PLAN FOR FURTHER DETAILS
SIGNATURE OF PERSON CONDUCTING DRILL:
SIGNATURE OF PERSON REVIEWING DRILL REPORT:
SIGNED
DATE
SIGNED
DATE
NOTE: PROVIDE A NARRATIVE SUMMARY OR ADDITIONAL INFORMATION ON SEPARATE PAGE, IF NECESSARY
ANNEX 2 – FIRE DRILL REPORT Revised July, 2009

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