(Example) Monthly Fire Safety Sheet Facility Name: _________________________________ Facility Address: __________________________________________ Monthly Fire Drills Monthly Checks: Smoke CO Year _____________________ Fire Extinguishers Detectors Detectors Month Date & Exit Staff Concerns Staff Date Date Date Time Time Initials Initials January 1/15/16 8:30 am 1.53 ML No Concerns ML 1/15/16 1/15/16 1/15/16 February 2/10/16 1:15 pm .54 VI Snow on sidewalk to meeting area VI 2/10/16 2/10/16 2/10/16 March 3/21/16 2:10 am 2.05 DG Room 201 refused to exit building DG 3/21/16 3/21/16 3/21/16 April 4/16/16 12:10 pm 1.13 ML Raining-exited to ML 4/16/16 4/16/16 4/16/16 May 5/3/16 9:30 pm 1.48 VI No Concerns VI 5/3/16 5/3/16 5/3/16
(Example) Monthly Fire Safety Sheet Facility Name: _________________________________ Facility Address: __________________________________________ Monthly Fire Drills Year _____________________ Monthly Checks: Fire Extinguishers Smoke Detectors CO Detectors Month Date & Time Exit Time Staff Initials Concerns Staff Initials Date Date Date January 1/15/16 8:30 am 1.53 ML No Concerns ML 1/15/16 1/15/16 1/15/16 February 2/10/16 1:15 pm .54 VI Snow on sidewalk to meeting area VI 2/10/16 2/10/16 2/10/16 March 3/21/16 2:10 am 2.05 DG Room 201 refused to exit building DG 3/21/16 3/21/16 3/21/16 April 4/16/16 12:10 pm 1.13 ML Raining-exited to ML 4/16/16 4/16/16 4/16/16 May 5/3/16 9:30 pm 1.48 VI No Concerns VI 5/3/16 5/3/16 5/3/16
16DC061-Attachment-A.docx