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International Medical Center

Fire Drill Evaluation

Unit Department Location

Date Time Shift

I Yes II
No I Staff Participation
I
R "Rescue"

Remove patients/visitors in imminent danger

A "Alarm"
Shout CODE RED
Pull station nearest alarm
Dial 3333 and report fire
C "Contain fire"
Close all doors
Place towel/blanket at base of door
Test door/handles
Portable 02 cylinders removed
Line oxygen shutdown
E "Extinguish"
propriate extinguisher to the area outside the room containing the fire
P.A.S.S. used to operate extinguisher
E "Evacuation" if unable to extinguish fire
Tag rooms to indicate they have been searched
Rescue methods used?
Aware of primary evacuation route and destination?
Aware of secondary evacuation route and destination?

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STEPS TAKEN TO TRAIN STAF RAEC & PASS

COMMENTS,SUGGESTIONS,OBSERVATIONS,RECOMMENDATIONS, DEFICIENCIES:

WAS DRILL SATISACTORY? DYES □NO

WILL A SECOND DRILL BE SCHEDULED DYES □ NO
CERITQYED BY:
SIGNATURE:
NAME:

POSITION:

Total Number of Staff:

Total Number of staff attending this fire drill

Total Number of staff who did not attend this fire drill

Date & Time of Next Scheduled fire Drill for those who Did NOT

attend

PLEASE RETURN COMPLETED FORM TO

Safety Officer Signature: I Safety Manager Signature:

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Department I Unit Dav Date

NO NAME POSITION IDNO DATE SIGN

01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24

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