Fire Drill Report

Home*

Date*

Date

Shift*

Time Initiated *

Hour Minutes

AM/PM Option

Staff Running Drill*

First NameLast Name

Position of staff running drill*

Staff participating

Please use initials

Location where fire was simulated*

Resident 1*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 1 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Individual 1: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 1 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 1 Time to exit minutes *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 1 Time to exit seconds*

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 1 exit used*

Resident 1 Awake or Asleep*

Resident 1 comments

Resident 2*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 2 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Resident 2 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 2 Time to exit minutes *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 2 Time to exit seconds*

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 2 exit used*

Individual 2: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 2 Awake or Asleep*

Resident 2 comments

Resident 3*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 3 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Resident 3 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 3 Time to exit minutes *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 3 Time to exit seconds *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 3 exit used*

Individual 3: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 3 Awake or Asleep*

Resident 3 comments

Resident 4*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 4 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Resident 4 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 4 Time to exit minutes *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 4 Time to exit seconds*

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 4 exit used*

Individual 4: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 4 Awake or Asleep*

Resident 4 comments

Resident 5*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 5 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Resident 5 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 5 exit used*

Individual 5: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 5 Time to exit minutes *

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 5 Time to exit seconds*

Time to exit please put the minutes in minutes and seconds in seconds, No words/letters are allowed. If The individual exited in less than a minute please put 0 in minutes. LOA is not an option.

Resident 5 Awake or Asleep*

Resident 5 comments

Resident 6*

When picking an individual if there is a vacancy in the home please click "Vacant" Listed before any of the homes.

Resident 6 Location *

If the individual is in the hospital/Skilled nursing facility in Location of individual you will click Hospital/Skilled nursing facility. If the individual is on vacation for 7 or more days click extended LOA.

Resident 6 Lowest Prompt Needed*

LOI’s – overall score, 5 = Individual Response, 4 = Verbal Cue, 3 = Gestural Cue or Model, 2 = Partial Physical, 1 = Full Physical, 0 = Resistance/Restraint/Refusal

Resident 6 Time to exit minutes*

Time to exit please put the minutes in minutes and seconds in seconds, If the individual exited in less than a minute please put 0 in minutes. No words/letters are allowed. LOA is not an option

Resident 6 Time to exit seconds*

Time to exit please put the minutes in minutes and seconds in seconds, If the individual exited in less than a minute please put 0 in minutes. No words/letters are allowed. LOA is not an option.

Resident 6 exit used*

Individual 6: Without going through the simulated fire was this the closest exit.*

YesNo

Resident 6 Awake or Asleep*

Resident 6 comments

Additional comments and/or issues identified during the evacuation drill

Emergency lights check & all in working order?*

YesNo

Smoke detectors check & and in working order?*

YesNo

All fire extinguishers fully charged?*

YesNo

Tags on each extinguisher initialed and dated?*

YesNo

All enunciators in working order?*

YesNoN/A

ICFs: Fire pull stations, Extinguishers and Fire Panels are free from obstruction

YesNo

Water Temps in CLA's should not exceed 120 degrees and in ICF's should not exceed 110 degrees

ICF homes- Amity, Janet, Maple, Ridge, and Scrub oak

All other homes are CLA

Water temp in kitchen*

Water temp in bathroom 1*

Water temp in bathroom 2*

Water temp in bathroom 3

If water temps exceeded the stated degrees was management notified?*

YesNoN/A

For homes that are not hard wired please list all smoke detectors that were checked and in working order*

For homes that are not hard wired please list all smoke detectors that were checked and not in working order*

If none write none

Adaptive equipment regarding fire safety checked and in working order (bed shakers, Strobe lights)*

YesNoN/A

If any smoke detectors were not working was management notified?*

YesNoN/A

Manger use only if any issues or concerns, Comments and/or Corrective Actions Needed