HOSPITAL

Fire Drill Observation Evaluation Form

Location of Observation: Casualty NO of Staff Present _____20_____

Date: 13/10/2017 Shift:  1st Time: _1PM  Scheduled Quarterly Drill

 2nd
 3rd

Fire Drill Location: Casualty

Section 1 – Immediate Staff Response Competently Points

Performed Scored
Did staff close all fire doors in the area, including patient room doors? Y es 10
Were the fire exit corridors cleared of unnecessary equipment? Yes 8
Did Staff inform Patients/Visitors of Alarm Condition? Yes 10
Did unit send a responder to the fires Point of origin? Yes 10
Sub Section Total 38

Section 2 – Staff Knowledge Competently Points

Performed Scored
Did Staff Know R.A.C.E. Yes 9
Did Staff Know P.A.S.S. Yes 8
Did staff know the location of Fire Alarm Pull Stations in their work area? Yes 10
Does staff know the location of fire extinguishers in their work area? Yes 10
Did staff know were the fire exits were in the drill area? Yes 5
Did staff know the evacuation procedure? Yes 7
Sub Section Total 49
Department Observation Scoring Grid Total Dept. Score
Add Sections 1 & 2
87
75 – 85 points = Excellent <60 points = Department In-service required
60 – 70 points = Acceptable

Section 3 – Fire Alarm Equipment Performance Equipment

Functioned
Points
Report all deficiencies to Engineering for Correction or Repair Scored
properly

Was the “CODE RED” Page audible in area being observed? Yes 10
Were fire alarm devices functioning properly in area observed? (chimes, strobes etc) (5pts.) Yes 10
Sub Section Total 20
Drill Total Score 107

Department Representative: _____________________________________________

Official Conducting Observation: _________________________________________

Fire Drill Observation In-service Attendance Sign In Sheet

 Date: 13/10/2017 Time: 1PM Observation Location: Casualty

Name Signature Department

** All Employees participating in the Fire In-Service Must Sign In **