MOCK DRILL REPORTING FORM

FORMAT NO: F/SRIRAM/ 15 REV NO: 01 REV.DATE:10-01-2019

Person Completing
Form and Title: MOCK DRILL – FIRE Date:

Attach to this form a list of all staff who participated in the drill, and any visitors participating.

Time to Evacuate:
Time Alarm Sounded: Time Drill Concluded:
(fire evacuation drills only)
Type of Drill: Notification / Alert Method: Weather Conditions:

 Fire / Evacuation  Bell or Buzzer  Clear

 Lockdown  Enhanced Alert System  Cloudy
 Modified Lockdown  Intercom  Raining
 Shelter-in-Place  Phone  Rain and wind
 Earthquake  Voice Notification  Windy
 Tsunami  Siren  Snow / Sleet
 Medical Emergency  Other: ______________  Hail
 Lahar
 Weather Emergency
 Other: __________________

Participants: (check all that apply) Situation at Start of Drill:

 Senior Management  Before Business Hours

 Safety Personnel  During Business Hours
 Employees/Staff  Peak Business Hours
 Security Officers  Lunch Time
 Law Enforcement  After Business Hours
 Fire Department  Other: _______________
 Emergency Medical Services _____________________
 County Emergency Mgmt.
 Other ___________________

Employees previously trained

Management previously trained on
on emergency procedures this
emergency procedures this year?
year?
 Yes  Yes
 No  No

Incident Command System Used? Incident Commander: Operations Chief:

 Yes
 No

PREPARED BY NAME APPROVED BY NAME

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MOCK DRILL REPORTING FORM
FORMAT NO: F/SRIRAM/ 15 REV NO: 01 REV.DATE:10-01-2019

Problems Encountered: (Check all that apply)

 Congestion in hallways  Radio communication problems

 Alarm not heard  Network / computer problems
 Employees unsure of what to do / proper  Noise impedes communications
 Staff unsure of responsibilities / response  Personnel not out of sight (lockdown drill)
 Weather-related problems  Long time to evacuate building
 Unable to lock doors  Personnel not serious about drill
 Windows not covered  Improper or unavailable supplies (SiP)
 Windows left open  Confusion
 Doors left open  Doors or Exits blocked
 Lights left on  Transportation
 Personnel not accounted for / attendance  Interagency miscommunications
 Difficulties with evacuation of disabled personnel,  Incident command problems
customers or visitors  Other: ____________________________
 Personnel unaccounted for (note # below) __________________________________

Extenuating Circumstances / Identified Factors / Special Conditions Simulated:

Mitigation / Plans for Improvement: (check all that apply and explain below)

 Additional management training  Cooperative planning with responders

 Additional staff training  Revised emergency procedures
 Address need for additional equipment  Other:
 Improved emergency supplies

Explain corrective efforts here:

PREPARED BY NAME APPROVED BY NAME

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