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Carilion Medical Center

Code Red Fire Event Evaluation

Please complete all questions electronically and click "Submit"

Do not print submit the paper form.

Was the event a drill or actual code event?

Drill	Actual Code

Date of Event (mm/dd format)

i.e. 05/28

Event shift
Select the shift during which the event occurred.

7A-3P	3P-11P	11P-7A

For what unit/department was the event called?

Building / Pavilion
Floor

Unit Reporting

Building / Pavilion
Floor

Name of Person Reporting

Was the event called for your unit/department?

Yes	No

Did you observe the following during the event?

Did you observe the following during the event?
	Yes	No	N/A
Exits (hallways) were clear and unobstructed.
Fire doors closed properly (automatically) and were not obstructed.
The overhead page was audible.
Did the fire response team have a clear leader?
Fire extinguishers were brought to the scene.
All corridor doors were manually closed.

If during a real emergency you were directed to evacuate, where would you take your patients?

(If submitting from a non-patient area please indicate N/A)

Building / Pavilion
Floor

Which is the appropriate person to give permission to turn off oxygen during a fire?

	Clinical Resource Nurse
	Respiratory Therapist
	Incident Commander or designee
	Unit Director
	Engineering/Maintenance
	N/A

Overall, the event was executed in a manner that was:

Very Good	Good	Fair	Poor	N/A - Drill not on unit

Suggestions / Comments

Please contact Taylor Richardson with any questions regarding this survey.