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Methodist Hospital

Physician Services Fire Drill/Alarm Activation Form

For Associated Event: Please select "No Event Selected" from the drop down box below.
Associated Event   
  Location of Drill/Alarm
  Time and Date of Activation
  Site/Department Reporting
  Staff was able to describe the term RACE as used in hospital fire policy? YES     NO     N/A    
  Staff was able to locate the nearest fire extinguisher? YES     NO     N/A    
  Staff was able to locate the nearest fire alarm pull station? If present on site? YES     NO     N/A    
  Staff was able to describe the procedure for using a fire extinguisher? PASS YES     NO     N/A    
  Staff was able to identify two exits/routes of escape? YES     NO     N/A    
  Oxygen cylinders are turned off if present? YES     NO     N/A    
  Office searched for patients, visitors, and/or staff? Doors closed as prepare for evacuation? YES     NO     N/A    
  Staff obtains knowledge on how to transfer patients, visitors, & staff to safe area/gathering site? YES     NO     N/A    
  Staff was able to state the designated gathering spot in parking lot? YES     NO     N/A    
  Head count was completed at safe area/gathering site? YES     NO     N/A    
  Were passageways free of obstacles? YES     NO     N/A    
  Comments:
  Evaluated By: