Home Name
*
Please Select
Adams
Brown
Blackstone
Deyo
Elm I
Elm II
Grace
Herkimer Hays
Herkimer Reagan
Herkimer Apt
Hill Place
Homecrest I
Homecrest II
Homecrest III
Glengarry
Madison
Marvin
Monroe
Napoleon
Pleasant I
Pleasant II
Pontiac Trail
Russell
Second
Sixth
Spring Arbor
Tipton
West
W. Washington
Westbrook
Westhaven
Westwood
CMH Agency
*
Please Select
Lifeways
Lenawee Count CMH
Summit Point
Washtenaw County CMH
Manager Name
Date
-
Month
-
Day
Year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
What is the Weather Condition
Type of Drill
Staff Surprised
Staff Knew in Advance
Actual Emergency
Training
Other
Type of Alarm in Home
Smoke Detector
Pull Station
Control Panel
Actual Emergency
Other
List the Consumer Initials separated by commas
List the Starting Location for the Drill Conducted
Which Exit did you use as the Fire Escape Route
Was Help Needed to Evacuate
Name of First Staff Member
Name of Second Staff Member
Name of Third Staff Member if Applicable
Describe what each staff did.
Check the Safety Items that were taken or performed during the evacuation drill
I took the keys and phone
I took the Emergency bag
I did a head count
I gave verbal praise given
I gave reinforcement
The evacuation route was clear
The Exit doors opened easily
The outside lighting was adequate
The Alarm worked and reset
The All Clear was given before reentry
Type of Reinforcer
What was the safe destination of your drill?
Length of Time to the Last person out the door
Name of Person Completing this form
Date
-
Month
-
Day
Year
Date
Home Manager
Comments
QI Comments
List corrective action if you indicated yes ( For Safety Committee Use)
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