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Momentum’s Outpatient Mental Health Clinic (OMHC)
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TRAINING
Home
About
Programs
Momentum’s Outpatient Mental Health Clinic (OMHC)
Psychiatric Rehabilitative Program Adult & Minor (PRP)
LGBTQ+ Division (PRP)
Substance Abuse Treatment
Client Info
Client instructions
Client Portal Login
Referral Form
Become a client today!
Resources
FAQ
Contact
Staff Portal
TRAINING
EMERGENCY DRILL FORM
Step
1
of
2
50%
Date
(Required)
MM slash DD slash YYYY
Person Completing Drill:
(Required)
First
Last
Email:
(Required)
This field is hidden when viewing the form
Type of Drill:
(Required)
Bomb Threat- Telephone/Suspicious Package
Fire
Medical
Power Failure
Severe Weather
Violent Behavior
Type of Drill:
(Required)
Bomb Threat- Telephone/Suspicious Package
Fire
Medical
Power Failure
Severe Weather
Violent Behavior
Time Drill Started:
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Time Drill Ended:
(Required)
Hours
:
Minutes
AM
PM
AM/PM
This field is hidden when viewing the form
Where program participant's involved:
(Required)
Yes
No
Where program participant's involved:
(Required)
Yes
No
Explain Participation
(Required)
MEDICAL
Indicate, what type of medical emergency was stimulated:
(Required)
VIOLENT BEHAVIOR
Indicate, what type of violet emergency was stimulated:
(Required)
BOMB THREAT
Indicate who was informed (by the receiver of call or finder of package) of the threat?
(Required)
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Were individuals moved to a safe location and all accounted for?
(Required)
Yes
No
This field is hidden when viewing the form
Was there a need for evacuation from the building?
(Required)
Yes
No
Where program participant's involved:
(Required)
Yes
No
Was there a need for evacuation from the building?
(Required)
Yes
No
Were people left in the building who did not move to a safe location?
(Required)
Yes
No
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Were people left in the building who did not move to a safe location?
(Required)
Yes
No
Describe:
(Required)
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Were emergency procedures followed?
(Required)
Yes
No
Were emergency procedures followed?
(Required)
Yes
No
Describe:
(Required)
Describe how staff responded to the drill:
(Required)
Do changes needed to me made to the policy/procedures?
Yes
No
This field is hidden when viewing the form
Do changes needed to me made to the policy/preocedures??
(Required)
Yes
No
Describe changes:
(Required)
I attest that the information provided is true to the best of my knowledge.
(Required)
