Form Sds 0342 - House Evacuation/fire Drill Record
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House Evacuation/Fire Drill Record
Aging and Physical Disabilities
Name of licensee:
Date:
Time:
AM
PM
AFH address:
Date of last fire drill conducted when residents
* Location of simulated fire:
are in bed:
* Point of safety:
Type of evacuation drill:
* Exit route:
Sleeping hours
Daytime
(Should vary location/route for each evacuation drill.)
Resident’s name
Resident evacuation times
(last, first, middle)
Individual
Required a
Description of assistance needed
evacuation time
substitute?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Other occupants
Individual
Required a
Description of assistance needed
(children, spouses, etc.)
evacuation time
substitute?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Total evacuation time:
Note: Total evacuation for all occupants must be
within three (3) minutes.
Caregivers present during evacuation drill
Minimum number of staff in the AFH
Note: The number of staff assisting residents during an evacuation drill
at any given time:
may not exceed the minimum number of staff in the AFH at any time.
Caregiver name
Used as a substitute
Role during drill
for a resident?
Yes
No
Yes
No
Yes
No
Signature of staff conducting drill:
SDS 0342 (4/12)
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