Republic of the Philippines

Department of Education
Region V
Division of Masbate
BALENO NATIONAL HIGH SCHOOL

EARTHQUAKE DRILL EVALUATION FORM

Date/Time:______________________________ Evaluator: ____________________________
Place of Drill: ____________________________ Location during the Drill: ________________

Check the line in accordance with the participant’s performance, 5 as the highest 1 as the
lowest.
1. Is the Siren/Alarm loud enough to heard by all drill participants?
1.____ 2. ____ 3. ____ 4. ____ 5. ____
2. Did the drill participants practice the DUCK, COVER, and HOLD technique during the
Alarm Phase (while the Siren is being sounded)?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
3. Did the drill participants evacuate during the Alarm Phase, waited for the Siren to stop
before evacuating?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
4. Did the drill participants follow the designated routes to evacuation area?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
5. Did the drill participants RUN, WALK Casually or walk faster than normal during the
Evacuation Phase?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
6. Did the drill participants bring any First Aid Kit or any item noticeable during the
Evacuation Phase?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
7. Did the drill participants conduct the headcount during the Headcount Phase?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
8. Is the evacuation area big enough to accommodate the evacuees?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
9. Did the first aid team properly apply first aid to the victim/s?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
10. Did the rescue team properly transfer the victim/s to the evacuation area?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____
11. Did the evacuation team properly perform their task (e.g. securing the important
documents and assets of the store)?
1. ____ 2. ____ 3. ____ 4. ____ 5. ____

Is there any observation during the drill? Please elaborate.

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Evaluator: ___________________________ Signature: ______________________________

Prepared by: Noted:

DIOSDADO E. SALIVIO RAMON S. BASAS, JR.

SDRRM Coordinator Principal - II