Monthly Emergency Drill Form
Above and Beyond Care requires emergency drills to be completed each month. Each direct support professional will be required to practice these drills on each shift at least once per month. This includes fire, tornado, and earthquake drills (do not practice all drills at the same time as the steps vary between drills, and that may confused the client). All emergency equipment should be tested monthly to ensure it is working properly.
Please complete this form and submit between the 1st and 5th of each month.
Client Name:
First Name
Last Name
DSP Name:
First Name
Last Name
Shift:
Location
Fire Drill
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Evacuation Started
Hour Minutes
AM
PM
AM/PM Option
Time Evacuation Ended
Hour Minutes
AM
PM
AM/PM Option
Tornado Drill
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Drill Started
Hour Minutes
AM
PM
AM/PM Option
Time Drill Ended
Hour Minutes
AM
PM
AM/PM Option
Earthquake Drill
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Drill Started
Hour Minutes
AM
PM
AM/PM Option
Time Drill Ended
Hour Minutes
AM
PM
AM/PM Option
Number of Fire Extinguishers
Number of Smoke Alarms
Date Tested
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was emergency equipment working properly?
Yes
No
Please note any deficiencies with emergency equipment as well as any repairs that were made (i.e. changed batteries in smoke alarm).
My signature indicates that all information submitted on this form is true and correct.
Submit
Should be Empty: