MONTHLY FIRE DRILL
Consumer Name
*
Date
-
Month
-
Day
Year
Date
Fire Drill Start Time
Hour Minutes
AM
PM
AM/PM Option
Fire Drill End Time
Hour Minutes
AM
PM
AM/PM Option
Was the consumer a willing participant?
Yes
No
If "no" briefly explain:
Number of participants involved in the fire drill (including yourself):
Please List Names
List any challenges or areas of difficulties during the drill (include a brief description of the startup fire drill):
DSW Staff Printed Name:
*
DSW Signature:
*
Date:
-
Month
-
Day
Year
Date
Consumer Signature
*
Date:
-
Month
-
Day
Year
Date
SIGNATURE OF FAMILY MEMBERS PRESENT:
Date:
-
Month
-
Day
Year
Date
SIGNATURE OF FAMILY MEMBERS PRESENT:
Date:
-
Month
-
Day
Year
Date
SIGNATURE OF FAMILY MEMBERS PRESENT:
Date
-
Month
-
Day
Year
Date
Preview PDF
Save
Submit
Submit
Should be Empty: