Pillar Homecare LLC

Pillar Homecare LLC

Emergency Drill Monthly Report
Month of Drill*
Client Name*

First NameLast Name
Client Address/Location of Drill*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Caregiver Conducting Drill *
Date of Drill*

MonthDayYear
Date
Start Time of Drill*

Hour Minutes

AM/PM Option
Number of Participants in Drill * *
*Note: At minimum caregiver and client must participate
Type of Drill *
Safety Strategy*
End Time of Drill*

Hour Minutes

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*

Clear
Caregiver Signature*

Clear
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.
Should be Empty:

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.