MOCK DRILL REPORT FOTMAT

1. Area & Location:

2. Mock drill conducted on Date: Time:
3. Number of persons :
4. Emergency situation : (Mack with an X)

(A) Fire ο
(B) Excavation collapse ο
(C) Fall from Height ο
(D) Emergency Evacuation ο
(E) Occupational Emergency ο
5. Name of observer :
6. Scenario :
7. Time of declaration of emergency :
8. Whether cordoning off area done : (Mark with an X) YES  NO 
9. Whether emergency alarm sounded : (Mark with an X) YES  NO 
10. First responder response time :
11. Whether worker assembled at assembly point: (Mark with an X) YES  NO 
12. Whether ambulance/Medical staff were called, and time taken accordingly:
13. Time of all clear :
14. Total time elapsed :
15. Previous total time :
16. Deficiency observed during the exercise :
17. Action recommended for improvement:
18. Name of person responsible to follow up, above: -
19. Other remarks:

No Recommendation Action Date

Observer(s) HSE Representative Site In Charge