Pillar Homecare LLC
Emergency Drill Report
Type of Drill
Monthly
Quarterly
Date of Drill
-
Month
-
Day
Year
Date
Client Name
*
First Name
Last Name
Client DOB
-
Month
-
Day
Year
Date
Client Address/Location of Drill
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Caregiver Present During Drill
*
Start Time of Drill
*
Hour Minutes
AM
PM
AM/PM Option
Number of Participants in Drill *
*
*Note: At minimum caregiver and client must participate
Type of Drill
*
Please Select
Fire
Hurricane
Tornado
Active Shooter
Safety Strategy
*
Please Select
Fire- RACE
Hurricane/Tornado- Secure location with no windows doors or evacuate
Active Shooter- safe location
End Time of Drill
*
Hour Minutes
AM
PM
AM/PM Option
Total time of Drill*
*Drill should be no less than 30 minutes to ensure full execution
If Conducting Fire Drill:
Yes
No
Was Alarm/Fire Extinguisher Present
Is Extinguisher in Working Condition
Was Caregiver/Client Able to Locate Extinguisher During Drill
Additional Remarks/ Areas of Reinforcement
Client or Responsible Party Signature
*
Caregiver Signature
*
Pillar Homecare Staff Conducting Drill
Drills should be alternated across shifts, if client receives AM and PM coverage. Records of drills are kept by on file in the client binder and at the Pillar Homecare LLC Main Office.
Submit
Should be Empty: