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Health and Safety Drill
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Location Name
Your answer
Organization Name
Your answer
Date of Report
MM
/
DD
/
YYYY
Report Completed By
Your answer
# of Drill Conducted in the Month
Your answer
Time of drill
Time
:
AM
PM
Type of Drill
Fire Drill
Bomb Threat
National Disaster
Utilities Shutdown
Medication l Incident
Overdoes
Domestic Violence
Attempted Suicide
Active Shooter
Hurricane
Tornado
Shelter In Place / Lock down
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Person Conducting Drill
Your answer
Date of Drill
MM
/
DD
/
YYYY
Length of Drill
Your answer
# of people participated
Your answer
# of people not present
Your answer
Method of notification
Your answer
Condition simulated / problems
Your answer
Was an alarm sounded for the drill?
Yes
No
Clear selection
Which areas of the facility were affected?
Your answer
Was an evacuation of these areas completed?
Yes
No
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If an evacuation was not completed, explain why.
Your answer
Effectiveness of the Drill
Unsatisfactory
1
2
3
4
5
Satisfactory
Clear selection
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