Health, Safety and Environment
2024 East Monument Street, Suite B200
Baltimore, MD 21205
Phone: 410.955.5918

Fire Incident Response Evaluation Form

Please fill out all fields.

Building:    Floor:  
Division:    Department:  
Shift: (optional)  Date:   (mm/dd/yy)  Time:   (hh:mm AM/PM)
Emergency Codes and Procedures
1. Does staff know the meaning of "CODE RED"?  
2. Does staff know the emergency phone Number?  
3. Does staff know the location of the nearest fire alarm pull station?  
4. Does staff know how to activate the fire alarm pull station?  
Response to Fire Alarm
5. Were person(s) in immediate danger evacuated?  
6. Were patients accounted for life support identified?  
7. Were corridors & egress routes clear?  
8. Were visitors cleared from corridors and directed to safe location?  
9. Were patients requiring assistance for evacuation identified?  
10. Did staff close all the doors in the area?  
11. Did all automatic fire/smoke doors close on the floor?  
12. Does staff know emergency oxygen shut off procedures for the unit?  
13. Does staff know the location of fire extinguishers on unit?  
14. Is staff familiar with building evacuation procedures?  
15. Is staff aware of total number of patients on the units?  
16. Does staff know the location of emergency transportation equipment?  
17. Was Alarm Visible?  
18. Was Alarm audible?  
19. Was Alarm understandable?  
20. Was Alarm location identified?  
All Clear
21. Was All Clear Called?  
22. Who responded to alarm?  
Follow-up needed? (optional)
Comments (optional)
Report Prepared by  
Badge ID (optional)
JHED ID (optional)
Score (optional for HSE use only)

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