Emergency Response Drill Checklist
Date of Drill:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Work Site
*
Work Site for PDF
Work Site (OLD)
24060 8th on 8th
24099 Canalta
24110 Beamers Gateway
25025 BPL Alpine Apartments
25132 Mountain Animal Hospital
26007 Charleston Phase 2
Type Site Name
Drill Lead By:
*
Email
example@example.com
Type of Drill:
*
Please Select
Evacuation
Medical Emergency
Rescue from Height
Explosion
Flood
Threat of Violence
Trench Collapse
Utility
Muster Point:
*
Evaluation
*
Rows
Yes/ No
Improvements Needed
Was the emergency response system tested?
Yes
No
Did everyone follow the evacuation routes?
Yes
No
Was the evacuation carried out in an orderly fashion?
Yes
No
Did everyone go to the designated meeting area(s) (muster point)?
Yes
No
Was there an accurate head count?
Yes
No
Were all communications equipment tested?
Yes
No
Did all communications equipment function properly?
Yes
No
Were any special hazards discovered?
Yes
No
Evacuation start time:
*
Hour Minutes
AM
PM
AM/PM Option
Evacuation end time:
*
Hour Minutes
AM
PM
AM/PM Option
Total evacuation time:
*
Total number evacuated:
*
Summary of completed drill:
(i.e. what worked well, what needs improvement)
Follow Up Action Required:
Corrective Action
Assigned to:
Target Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Corrective Action
Assigned to:
Target Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Completed:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Improvements/Corrections Made:
Attendance Sheet
*
Upload or take a picture
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit
Should be Empty: