Health, Safety and Environment
2024 East Monument Street, Suite B200
Baltimore, MD 21205
Phone: 410.955.5918
Web: http://www.hopkinsmedicine.org/hse

Fire Incident Response Evaluation Form

Please fill out all fields.


Emergency Codes and Procedures

1. Does staff know the meaning of "CODE RED"?	YesNoN/A
2. Does staff know the emergency phone Number? Centrex: 5-4444	YesNoN/A
3. Does staff know the location of the nearest fire alarm pull station?	YesNoN/A
4. Does staff know how to activate the fire alarm pull station?	YesNoN/A

Response to Fire Alarm

5. Were person(s) in immediate danger evacuated?	YesNoN/A
6. Were patients accounted for life support identified?	YesNoN/A
7. Were corridors & egress routes clear?	YesNoN/A
8. Were visitors cleared from corridors and directed to safe location?	YesNoN/A
9. Were patients requiring assistance for evacuation identified?	YesNoN/A
10. Did staff close all the doors in the area?	YesNoN/A
11. Did all automatic fire/smoke doors close on the floor?	YesNoN/A
12. Does staff know emergency oxygen shut off procedures for the unit?	YesNoN/A
13. Does staff know the location of fire extinguishers on unit?	YesNoN/A

Evacuation

14. Is staff familiar with building evacuation procedures?	YesNoN/A
15. Is staff aware of total number of patients on the units?	YesNoN/A
16. Does staff know the location of emergency transportation equipment?	YesNoN/A

Alarm

17. Was Alarm Visible?	YesNoN/A
18. Was Alarm audible?	YesNoN/A
19. Was Alarm understandable?	YesNoN/A
20. Was Alarm location identified?	YesNoN/A

All Clear

21. Was All Clear Called?	YesNoN/A

22. Who responded to alarm?

Follow-up needed? (optional)	YesNo

Comments (optional)

Report Prepared by

Badge ID (optional)

JHED ID (optional)

Title

Score (optional for HSE use only)