AFH Evacuation/Fire Drill Record
Office of Licensing and Regulatory Oversight
Name of licensee:
Date:
Time:
AM
PM
AFH address:
Date of last fire drill conducted when residents
are in bed:
• Location of simulated fire:
• Exit route:
Type of evacuation drill:
Sleeping hours
Daytime
• Initial point of safety:
• Final point of safety:
Resident’s name
(last, first)
(Should vary location/route for each evacuation drill.)
Resident evacuation times to initial point of safety
Individual
Substitute
Description of assistance needed
evacuation time required?
Yes
Yes
Yes
Yes
Yes
Other occupants
(children, spouses, etc.)
Individual
evacuation time
Substitute
required?
Yes
Yes
Yes
Yes
Yes
Total evacuation time:
No
No
No
No
No
Description of assistance needed
No
No
No
No
No
Note: Total evacuation for all occupants to the initial point of
safety must be within three (3) minutes or less.
Caregivers present during evacuation drill
Minimum number of staff in the
Note: The number of staff assisting residents during an evacuation drill
AFH at any given time:
may not exceed the minimum number of staff in the AFH at any time.
Used as a
Caregiver name
substitute for
Role during drill
a resident?
Yes
Yes
Yes
No
No
No
Signature of staff conducting drill:
SDS 0342 (rev. 7/15)