Emergency Plan Manual

DISASTER DRILL REPORT FORM Date of Drill:____________________________ day of Week: ___________________________ Type of Drill: 9 Natural Disaster 9 Hurricane 9 Industrial Accident 9 Blackout 9 Communication Failure 9 Program Site Damage 9 Power Failure 9 Other:__________________ Time Started: __________ Time Completed: __________ Time Lapsed: ___________ Person in Charge of Drill:________________________________________________________ Time Agency Personnel Notified of Drill:__________________________ Location of Simulated Disaster: ___________________________________________________ Escape Route Used: _____________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Point of Safety Used: ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Communication with Patients/Staff discussed?________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What Patients or Staff Refused to Participate?_________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Exit Lights Checked? 9 Yes 9 No Emergency Lights Checked? 9 Yes 9 No Other Equipment Checked? 9 Yes 9 No Please Specify:_________________________________________________________________ Additional Comments:___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________ ________________________ Signature/Title Date