Drill and Incident Review Report Form, A-9

Drill and Incident Review Report Form, A-9

(on the pages that follow)

County: / Drill/Incident Review Form
☐ DRILL / ☐ ACTUAL INCIDENT
School: / Date: / # Visitors
Person Completing Form and Title: / # Students / # Staff
Start time: / Protective response time: / Accounted for time: / End time: / Total length of time:
Drill/Incident: (check all that apply) / School Facility: (check all that apply) / Weather: (check all that apply)
☐ Fire/Evacuation
☐ Active Shooter/Armed Intruder
☐ Inside school
☐ outside school
☐ Lockdown – Precautionary
☐ Lockdown – Emergency
☐ Shelter In Place (Weather)
☐ Shelter In Place
(Chemical or HAZMAT)
☐ Bomb Threat
☐ Evacuation
☐on site ☐ off site
☐ Earthquake
☐ Medical Emergency
☐ Other______/ ☐ Elementary
☐ Intermediate
☐ Middle School or Junior High
☐ High School
☐ Vocational
☐ Alternative
☐ Transportation Building
☐ Administration Building
☐ Pre-school
☐ School-based Daycare Center
☐ Bus(es)
☐ Other______/ ☐ Clear
☐ Foggy
☐ Cloudy
☐ Raining
☐ Windy
☐ Snow/Sleet/Freezing Rain
☐ Hail
☐ Flash Flood Watch/Warning
☐ Tornado Watch/Warning
☐ Hot (Above 80 degrees F)
☐ Cold (10 – 40 degrees F)
☐ Severe Cold (below 10 degrees F)
☐ Other______
Participants: (check all that apply) / Notification(check all that apply) / Situation at Start of Drill/Incident
☐ School Administrators
☐ Teachers / para-educators
☐ Custodial Staff
☐ Kitchen Staff
☐ Students
☐ School Resource Officer (SRO)
☐ Law Enforcement
☐ Fire Department
☐ Emergency Medical Services
☐ County Emergency Management
☐ Parents and/or Volunteers
☐ Other______/ ☐ Bell or Buzzer
☐ PA system announcement
☐ Enhanced Alert System
☐ Intercom
☐ Phone
☐ Voice/In person
☐ Bull horn
☐ Siren
☐ Reverse 911
☐ Two-way Radio / walkie-talkie
☐ Web-based mass notification
☐ Other______/ ☐ Before School (student drop off)
☐ During Class
☐ Between Classes (transition)
☐ Recess
☐ Lunch
☐ Assembly
☐ After School (student pick up)
☐ Indoor Athletic/Community Event
☐ Outdoor Athletic/Community Event
☐ Other______
What system was used for head count? ☐ Red/Green Card
☐ Other______/ Was staff previously trained or drilled on scenario this year?
☐ YES ☐ NO / Were students previously trained or drilled on scenario this year?
☐ YES ☐ NO
Incident Command System used?
☐ YES ☐ NO / Any substitute teachers present?
☐ YES ☐ NO / Language used:
☐ Plain Language ☐ Codes
Did debriefing occur?
☐ YES ☐ NO / Did plans for students with special needs work?
☐ YES ☐ NO ☐ N/A / Is this a drill to fulfill recommended or required minimums?
☐ N/A ☐ YES ☐ NO, this exceeds minimum recommended/required
Problems Encountered(check all that apply and explain below)
☐ Congestion in hallways
☐ Alarm not heard
☐ Announcement/updates not heard
☐ Students unsure of what to do or where to go
☐ Staff unsure of responsibilities
☐ Weather related problems
☐ Unable to lock doors
☐ Windows not covered, if instructed to do so
☐ Windows left open
☐ Emergency windows were obstructed
☐ Doors or exits were blocked/obstructed
☐ Students not accounted for
☐ Difficulty evacuating persons with special needs
☐ Staff or other adults not accounted for
☐ Staff or students not serious about the drill
☐ Slow evacuation time
☐ All persons did not evacuate as instructed
☐ Personal belongings not left behind as instructed / ☐ Radio communication problems
☐ Noise impeded communications
☐ Teachers/classrooms could not communicate with main office or established command post
☐ Some students were frightened or emotional
☐ Substitutes not prepared
☐ Administration go kit was not ready/missing items
☐ Teacher / classroom go kits were not ready
☐ Transportation was inadequate
☐ Unable to reach evacuation site
☐ Necessary medications were not available
☐ Keys to off-site evacuation bldg. could not be found
☐ CRT members did not know how to shut down HVAC
☐ Interagency miscommunications
☐ Incident command issue
☐ Parental complaints/confusion re: drill/reunification
☐ Members of CRT were absent, no alternates trained
☐ Other______
Lessons Learned and Explanations of Problems Encountered
Additional Considerations: How will information be collected from staff, students and others?
Who observed the drill/incident to assess and provide feedback? Were there any exemplary practices?
Corrective Action Plan
☐ Additional staff training /drills
☐ Additional student training /drills
☐ Address need for additional equipment
☐ Improve emergency supplies / ☐ Cooperative planning with responders
☐ Revise emergency plans / procedures
☐ Improve communication
☐ Other______
Explain in more detail the correction needed. (Be sure that your corrective action is achievable.)
Assign person(s) responsible to complete corrective action. / Date corrective action will be completed.
If this was NOT A DRILL, but an ACTUAL INCIDENT, did drills help prepare your school and stakeholders to respond?
☐ YES ☐ NO ☐ N/A Was a drill
SCHOOL CRISIS RESPONSE TEAM:
COMMUNICATIONS
  • Notification made to:
/ ☐ 911 / ☐ Superintendent / ☐ Transportation
  • PA/Intercom System:
/ ☐ Announced crisis / ☐ Heard everywhere / ☐ Not Used
  • Classes outside were notified by:
/ ☐ Two-way radio / ☐ Runner / ☐ Other
  • Fire alarm was
/ ☐ Activated / ☐ Heard everywhere / ☐ Not Used
  • Parental notifications
/ ☐ Mass alert system / ☐ Other______/ ☐ Media/press
  • Precautionary lockdown, sign was
/ ☐ Posted on door(s) / ☐ No sign posted / ☐ Other
SECURING FACILITY/ACCOUNTING FOR PEOPLE
  • All exterior doors were:
/ ☐ Checked & closed / ☐ Locked
  • Areas swept for students in
/ ☐ Restrooms / ☐ Common areas / ☐ Hallways
  • Persons found during sweep:
/ ☐ Secured in safe room / ☐ Returned to class / ☐ Evacuated
  • Were two-way radios used?
/ ☐ Yes / ☐ No
  • Go Kit brought to assembly area?
/ ☐ Yes / ☐ No
  • Go Kit contained needed items?
/ ☐ Yes / ☐ No
  • HAZMAT event, HVAC shut down
/ ☐ Yes / ☐ No / ☐ N/A
  • Other utilities shut down
/ ☐ Natural Gas / ☐ Water / ☐ Electrical
  • Students witnessing event were
/ ☐ Debriefed / ☐ Counseled / ☐ Parents notified / ☐ N/A
EVACUATION/REUNIFICATION (if implemented)
  • Buses/Transportation
/ ☐ Went as planned / ☐ Had issues / ☐ Not Used
  • Evacuation routes
/ ☐ Worked well / ☐ Had issues / ☐ Not followed
  • How were parents notified?
/ ☐ Mass alert system / ☐ Other______/ ☐ Media/press
  • Did parents follow instructions?
/ ☐ Yes / ☐ No
  • Did Go Kit contain needed items?
/ ☐ Yes / ☐ No
  • All medical and Rx needs met?
/ ☐ Yes / ☐ No
STUDENT AND STAFF RESPONSE
Classroom doors were / ☐ Locked / ☐ Unlocked/closed / ☐ Open
Classroom lights were / ☐ Turned off / ☐ Left on / ☐ Some on/some off
Windows were / ☐ Kept open / ☐ Closed / ☐ Some open/closed
Classroom go-kits were / ☐ Brought/available / ☐ Complete / ☐ Missing items
Evacuation, students exit building/room / ☐ Orderly/calm/quiet / ☐ Confused/scared / ☐ Mixed responses
Evacuation, proper route(s) used / ☐ Yes / ☐ No
Evacuation, was to / ☐ On campus / ☐ Off campus site / ☐ Multiple sites
Evacuation, proper evacuation site used / ☐ Yes / ☐ No
Evacuation, buddy systems worked / ☐ Yes / ☐ No / ☐ N/A
Reverse Evacuation, students entered / ☐ Orderly/calm/quiet / ☐ Confused/scared / ☐ Mixed responses
HAZMAT incident, windows were also / ☐ Taped, closed / ☐ Closed / ☐ Some open/closed
Shelter In Place, students/staff: / ☐ All knew where to go / ☐ None knew where / ☐ Some knew where
Armed intruder, students/staff chose to / ☐ Evacuate/run / ☐ Lockdown/hide / ☐ Fight
Armed intruder, action taken done well? / ☐ Yes ☐ No / ☐ Yes ☐ No / ☐ Yes ☐ No
Were any medical treatment(s) used? / ☐ First Aid / ☐ CPR / ☐ AED
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