"Fire/Tornado Drill Evacuation Drill Report Template for Hcs and Cps Homes"

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Fire/Tornado Drill Evacuation Drill Report
For HCS and CPS Homes
Group Home: yes ____
no ____
Foster Home: ____________________________________
Date: ________________________
Address: ________________________________________
Exact start time of drill: ___________
________________________________________
Exact end time of drill: ___________
Actual Fire
Fire Drill
Actual Tornado
Tornado Drill
Other Emergencies:
Was this a sleep time drill? yes ____ no____
Activity going on at time of drill:_______________________________________________________________
In case of an actual fire, indicate location of fire: __________________________________________________
Was emergency help called to the scene: yes ____
no ____
List the names of individuals present during drill (including parent/s): __________________________________
_________________________________________________________________________________________
Number of clients in the home: ________
Number of bio/adopted kids in home: ________
Total time to clear the building of all household members: minutes: ______ seconds: ______
Problems/Comments:________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Complete the information pertaining to clients:
1. Level of resistance: minimal____
mild ____
strong ____
2. Level of physical mobility: self starting ____
slow ____
needed help ____
3. Level of consciousness during drill/evacuation:
fully conscious ____
partially conscious ____
unconscious ____
4. Amount of help needed to evacuate:
needed 1 or more parent/s ____
needed no help from parent/s ____
5. Response to instructions:
followed instruction ____
required supervision ____
did not respond ____
6. Response to alarm while sleeping:
responded ____
responded with help ____
did not response ____
7. Completed evacuation immediately without prompting: yes ____
no ____
8. Stayed at designated safe place without prompting: yes ____
no ____
9. Are parents/occupants adequately trained on evacuation procedures: yes ___
no ___
10. Was emergency help called to the scene: yes ___
no ___
IMPORTANT: Note any plans for improving results of future drills for potential emergences:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
At least one fire drill a year needs to occur during sleep hours. All fire drills are to occur without the clients prior knowledge.
Total time to complete the drill should be under three minutes.
Rev 9/08
Fire/Tornado Drill Evacuation Drill Report
For HCS and CPS Homes
Group Home: yes ____
no ____
Foster Home: ____________________________________
Date: ________________________
Address: ________________________________________
Exact start time of drill: ___________
________________________________________
Exact end time of drill: ___________
Actual Fire
Fire Drill
Actual Tornado
Tornado Drill
Other Emergencies:
Was this a sleep time drill? yes ____ no____
Activity going on at time of drill:_______________________________________________________________
In case of an actual fire, indicate location of fire: __________________________________________________
Was emergency help called to the scene: yes ____
no ____
List the names of individuals present during drill (including parent/s): __________________________________
_________________________________________________________________________________________
Number of clients in the home: ________
Number of bio/adopted kids in home: ________
Total time to clear the building of all household members: minutes: ______ seconds: ______
Problems/Comments:________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Complete the information pertaining to clients:
1. Level of resistance: minimal____
mild ____
strong ____
2. Level of physical mobility: self starting ____
slow ____
needed help ____
3. Level of consciousness during drill/evacuation:
fully conscious ____
partially conscious ____
unconscious ____
4. Amount of help needed to evacuate:
needed 1 or more parent/s ____
needed no help from parent/s ____
5. Response to instructions:
followed instruction ____
required supervision ____
did not respond ____
6. Response to alarm while sleeping:
responded ____
responded with help ____
did not response ____
7. Completed evacuation immediately without prompting: yes ____
no ____
8. Stayed at designated safe place without prompting: yes ____
no ____
9. Are parents/occupants adequately trained on evacuation procedures: yes ___
no ___
10. Was emergency help called to the scene: yes ___
no ___
IMPORTANT: Note any plans for improving results of future drills for potential emergences:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
At least one fire drill a year needs to occur during sleep hours. All fire drills are to occur without the clients prior knowledge.
Total time to complete the drill should be under three minutes.
Rev 9/08