EARTHQUAKE DRILL

EARTHQUAKE DRILL
Earthquake Drills are to be conducted at least once per quarter at each location. This form also is completed when an actual earthquake occurs.

Please refer the the Emergency Management policy in the Emergency Binder to ensure the protocols were properly followed.
Type

DrillActual
Staff Submitting Form

First NameLast Name
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Name of Site
Facility Address
IF INSIDE
Staff and clients executed Drop, Cover and Hold on procedure?

YESNO
Staff and clients covered the backs of their head with their arms?

YESNO
Staff and clients stayed away from windows, bookcases or tall, and heavy furniture?

YESNO
Staff and clients covered the backs of their head with their arms?

YESNO
Everyone stayed in place until the shaking stopped?

YESNO
Once the shaking stopped the designated staff checked all areas to see that the clients were safe - away from windows, and check for fallen objects?

YESNO
Staff and clients did not run outside. If aftershock, everyone is prepared to move back to their safety spot?

YESNO
Staff accounted for the safety of staff and clients by calling out each individual’s name located at the site and conducting a head count?

YESNO
IF OUTSIDE
Staff gathered clients away from flying/falling objects and to encourage them to stop still, crouch down and cover the backs of their heads with their arms?

YESNO
Staff accounted for the safety of all persons under their supervision by calling out each individual’s name at their location and conducting a head count?

YESNO
AFTERWARDS
Did staff is to assemble all clients in front of the building and conducted a headcount accounting for all clients and staff?

YESNO
Staff inspected the building for unaccounted staff or persons served and secure the site safety binder with emergency contact telephone numbers?

YESNO
Gas, Water and Power functional?

YESNO
Gas, Water or Power shut off?

YESNO
The staff notified the Facility Administrator/CCM and Chief Compliance Officer and await further instructions?

YESNO
If persons served or staff is injured, qualified staff will administer CPR/First Aid and call 911 for assistance?

YESNO
The designated staff member completed an Incident Report and submitted it to the Facility Administrator/CCM and Chief Compliance Officer?

YESNO
Signature

Clear
Should be Empty:

EARTHQUAKE DRILL

IF INSIDE

IF OUTSIDE

AFTERWARDS