Fire Drill – Life Time Skill Home

Name of Individual #1 Serviced(Required)

Name of Individual #2 Serviced (if applicable)

Address:(Required)

Name of Staff #1 Involved:(Required)

First Name Last Name

Name of Staff #2 Involved (if applicable)

First Name Last Name

Date and Time of Fire Drill(Required)

Time(Required)

Awake or Asleep?(Required)

Awake

Asleep

*** Fire Drills and System Checks (including all smoke detectors) must be performed and recorded monthly. Once every three months, the fire drills must be held when the individuals are asleep (11pm to 7am).***

Designated Meeting Area:(Required)

Location of Fire:(Required)

Basement Bathroom Bedroom Dining Room Hallway Kitchen Living Room

Exit Used:(Required)

Time for Individual #1 to Exit the Home (state in minutes and seconds):(Required)

Time for Individual #2 to Exit the Home (if applicable)(state in minutes and seconds):

***If exit takes longer than 2 min 30 sec, another drill needs to be completed in the same month***

Number of Smoke Detectors Tested:(Required)

Number of Smoke Detectors Inoperable:(Required)

Smoke Detector's Location Used for Fire Drill:(Required)

Are all of the extinguishers charged (i.e., arrow in the green area) and accessible to staff and individuals?

Yes

Fire Extinguisher Tag Signed and Dated.(Required)

Yes

Did you encounter any difficulties during this Fire Drill?(Required)

Yes

Supervisor's Name:(Required)

If Applicable, enter name:

Date(Required)

Signature(Required)