Stabilization and Crisis Unit / House Evacuation/Fire Drill Record
Indicated if: Quarterly or New Client Entrance Drill
Home: / Date: / / / / / Time: / : / AM PM
Client name: / Mo / Day / Year
Client name IF Drill is an “Entrance Drill”
House Evacuation / Fire Drills must vary location / route on each drill. Swing and Night Shifts.
Reasonable evacuation time: / * / Location of simulated fire:
Awake or sleeping: 3 Minutes
* / Exit route:
*Must vary location/route each drill.
Client’s name
(Last name, first initial) / Evacuation time in minutes / Comments
0.5 / 1 / 1.5 / 2 / 2.5 / 3 / 3.5 / 4 / 4.5 / 5
Indicate client’s level of assistance
Client’s name / Level of assistance as identified on RTR/safety plan: / Level of assistance needed today:
Magnetic door test
Door checked: / Door status (describe problem submit DHS 4612 Work Order Form/Contact Contract Provider)
Front door: Yes No
Back door: Yes No
Side door: Yes No
Other (1) : Yes No
Other (2) : Yes No
Staff present (All staff on premises must participate in drill and sign below :)
Signature of staff conducting drill:
Signature of sitemanager:
**Follow up “Actions Taken”(in response to today’s drill) describe details below:
Follow-upManager signature: / Date:

SOCP House Evacuation/Fire Drill Procedures

Reference:OAR-411-325-0240, 411-325-0250

New Admit/Transfer:

Assess the level of evacuation assistance required for all new clients entering the program within 24 hours of arrival. Document assistance needed on the DHS 4637H - House Evacuation/Fire Drill Record(level of assistance needed today), and retain this information in the individual’s entry records, as well as Risk Tracking Record (RTR).

General Fire Drill requirements:

  1. Conduct unannounced fire/evacuation drills when individuals are present in the home one time quarterly on day, swing and night Shift. Additional fire drills may be conducted if based on particular circumstances of individuals living in the home, it is felt more drills are needed
  2. Each time a house evacuation fire drill is conducted, vary the time of drill
  3. Each time a house evacuation fire drill is conducted, vary the fire drill exit route based on the location of the simulated fire.
  4. Indicate client last name in “client name sections”. You may add a first initial, however it is not required.
  5. Indicate evacuation time in minutes. Clients must evacuate within 3 minutes.
  6. Identify level of assistance for each client as indicated on the Risk Tracking Record (RTR)/Safety Plan at entry, Annual ISP, and when changes occur.
  7. Indicate the actual client level of assistance needed for each evacuation drill.
  8. All staff present in the home must participate and sign the DHS 4637H - House Evacuation/Fire Drill Record.
  9. The staff conducting the House Evacuation/Fire Drill must sign the evacuation drill form.
  10. The Site Manager will review, sign and indicate any follow-up needed with approximate date of completion in response to client issues, magnetic door testing or staff training needed.
  11. When follow-up has been completed, the site manager will again review, sign and date the “House Evacuation/Fire Drill Record.”
  12. DHS 4637H - House Evacuation/Fire Drill Record(s) must be maintained at the home for 2 years, correlating with “Licensing” visits.
  13. Fax a copy to “Safety Manager” (503) 378-5917

Magnetic Lock(s) Group Homes
Engaging and Disengaging Magnetic Locks information is to be kept in the “Fire Evacuation Book.”
  • Use DHS 4618 Magnetic Lock(s) Disengage Doors and Gates Procedures/Contacts form.
  • Magnetic door/gate testing must occur during day and swing evacuation drills and be documented on the DHS 4637H - House Evacuation/Fire Drill Record.
  • Magnetic lock/disengage written procedures are required for all magnetic locked homes. All staff must have access to the procedure in the event of a Safety Check Inspection, Licensing, or in the event of an emergency.
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#5.004 Evacuation Drills OAR 411-325-0240; 411-325-0250; 411-345-0250 DHS 4637H (02/14)