MOCK EMERGENCY DRILL FORM TEMPLATE This form is a template and may be modified based on service settings and other agency requirements. When using this form, consider adding or deleting topics that are applicable to the people receiving services in the program.
MOCK EMERGENCY DRILL
Date:
Time:
Location:
Description of the emergency scenario used for drill:
Medical
Staff response
Please explain
Was the person checked for responsiveness?
Yes No
Was there an internal call for help? Did staff simulate calling 911? Were CPR, abdominal thrusts or other interventions begun correctly and in a timely manner? Was the person moved to a different area/location to begin interventions?
Yes No Yes No
Yes No
Yes No Was anyone directed to meet EMS? Yes No Were other people receiving services removed from the scene? Yes No
Did staff remain with the person while waiting for EMS to arrive? Were details of the event correctly conveyed to EMS? Were agency emergency procedures followed?
Yes No
Yes No
Yes No
Yes No
Fill in
Behavioral/Other
Staff response
Please explain
Did staff notify the appropriate or required point of contact? Were any interventions provided?
Yes No
Yes No Did the person refuse medications? Yes No Did the person refuse to attend program or group sessions? Yes No Fill in Yes No
Fill in
Yes No
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