CCH Fire Drill

Home Name*
CMH Agency*
Manager Name
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
What is the Weather Condition
Type of Drill

Staff SurprisedStaff Knew in AdvanceActual EmergencyTrainingOther
Type of Alarm in Home

Smoke DetectorPull StationControl PanelActual EmergencyOther
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 phoneI took the Emergency bagI did a head countI gave verbal praise givenI gave reinforcementThe evacuation route was clearThe Exit doors opened easilyThe outside lighting was adequateThe Alarm worked and resetThe 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

MonthDayYear
Date
Home Manager
Comments
QI Comments
List corrective action if you indicated yes ( For Safety Committee Use)
Should be Empty: