Pillar Homecare LLC
Emergency Drill Monthly Report
Month of Drill
*
Please Select
September
October
November
December
January
February
March
April
May
June
July
August
Client Name
*
First Name
Last Name
Client Address/Location of Drill
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Caregiver Conducting Drill
*
Date of Drill
*
-
Month
-
Day
Year
Date
Start Time of Drill
*
Hour Minutes
AM
PM
AM/PM Option
Number of Participants in Drill *
*
*Note: At minimum caregiver and client must participate
Type of Drill
*
Please Select
Fire
Hurricane
Tornado
Active Shooter
Safety Strategy
*
Please Select
Fire- RACE
Hurricane/Tornado- Secure location with no windows doors or evacuate
Active Shooter- safe location
End Time of Drill
*
Hour Minutes
AM
PM
AM/PM Option
Total time of Drill*
*Drill should be no less than 30 minutes to ensure full execution
Fire/Smoke Alarm System or Extinguisher, if applicable
Yes
No
Was Alarm/Fire Extinguisher Present
Was System/Fire Extinguisher used for drill
If Used, did the system operate properly
Additional Remarks/ Areas of Reinforcement
*
Client or Responsible Party Signature
*
Caregiver Signature
*
Each site is required to conduct 1 monthly Drill. One should be done for AM and PM if appropriate. Records of drills are kept by on file in the client binder and at the Pillar Homecare LLC Main Office.
Submit
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