*McLAREN LAPEER REGION - Fire Alarm Observation Sheet

Note: Fields marked with an * indicates required field

Fire Alarm Observation Sheet

Fire Alarm Observation Sheet

The designated person in charge must complete this form, whenever alarm is initiated and forwarded to Plant Operations.

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

5. Did all automatic fire doors within your department close and latch? *

Yes

No

N/A

6. Was corridor and nurse station lighting level returned to full intensity? *

7. Did employees remove/clear all objects from corridors? *

8. Staff can verbalize where they would transfer patients if evacuation of the area was necessary? *

9. Staff can verbalize what methods are used to transport patients if evacuation is necessary? *

Comments:

Date of alarm (mm-dd-yyyy): *

Time of alarm: *

Paged location of Code Red: *

Full Name of Observer: *

Department *

Birth Center - Waiting Room, Patient Rooms, Nurse Station, C-Section Suite, Locker Rooms/Offices

Communications - Operator, Mail Room/Central Copy

Diagnostic Imaging - Cath Lab, Central Elevator, Diagnostic/Waiting Area, MRI/Cat Scan Ultrasound

Emergency Dept - Entire Suite, Registration Area

Endoscopy - Entire Suite, Staff Lounge

Food and Nutrition - Kitchen, Storeroom, Dining Room (not staffed 8pm-5am)

Ground Floor South - Cardiac Rehab/Pulmonary Rehab, Conference Rooms 4-5, Education Room/Sim Lab, Quality Mgmt

ICU - Waiting Room, Equipment Storage Room, Nurse Station, Patient Rooms

Laboratory - Offices, Waiting Area, Work Area, North Elevator

Laundry/HSKP - Clean Linen, Soiled-Sorting, Storage Room, Work Area

Medical Records - Offices, Department, Corridor (not staffed 4:30 pm - 6:00 am)

Nuclear Medicine - Echo Room, Entire Area

Outpatient Services - Entire Suite, Pain Clinic, PET/CT

OR - OR/Recovery Rooms, CS

Outpatient.Dialysis - Entire Suite

Patient Access - Offices, Information Desk, Lobby, Gift Shop

Pharmacy - Entire Suite

PCU - Patient Rooms, Waiting Areas, Work Areas

Plant Operations - Department/Office, Work Area/Print Room, South Boiler Room

Respiratory Services - All Treatment/ Exam Rooms, Stress Lab, Waiting Room (include both areas)

Supply Chain Mgmt - Offices, Loading Dock, Storerooms

Telemetry 2 - T2, Patient Rooms, Work Area

Telemetry 3 - T3/PCU - Entire Suite

Transitional Care - Entire Suite

1 South Ortho - Entire Suite Joint Express

2 South Behavioral Health - Entire Suite

3 South

Other

If Other, please specify:

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