Name and Address of School: (please print except when signing the signature line.)
______________________________________________________________
______________________________________________________________
(Please place an “x” in the appropriate boxes below.)
a) Annual Review
Yes No
(1)
☐ ☐
(2) ☐ ☐
Annual Review Date(s): ________________________________________________________________________________
b) Attendance Record In addition to your school’s principal (or designee), the following parties are required to participate in your school’s
annual review:
Principal(s) or designee(s): ____________________________________________________________________
Representatives from local first responder organizations (fire and/or police) who participated, advised and consulted in the review
process (please identify their representative organization):
Any other persons who will aid in the review process, including but not limited to, any members of any education-related organization or
the first responder or emergency management community:
c) Certification
(address) has occurred.
located
at
By signing below, the undersigned certifies (1) that the parties listed above were invited to the annual review and provided with a
minimum of 30-days’ notice before the date of the annual review; and (2) an effective review of the emergency and crisis response plans,
protocols and procedures and the school safety drill programs for all/every school building at _____________________________
___________________________________________
By signing below, the undersigned certifies that the subject school will implement those plans, protocols, procedures and programs during
the upcoming academic year.
Title: _Name: ____________________________________________________________ _______________________________________________
Signature: Date: _____________________________________________________________ ____________________________________________
This report is to be completed each calendar year. A copy of this Report is to be sent to each party that participates in the review, such as Fire
Department, Fire Protection District, Police Department or Sheriff’s Department. The original Report is to be sent each calendar year to the Office of
the State Fire Marshal. This form may be emailed to SFM.FirePreventionAA@illinois.gov or mailed to: Office of the State Fire Marshal, Division of
Fire Prevention, 1035 Stevenson Drive, Springfield, IL 62703.
Private School Annual Review Compliance Report
School Safety Drill Act (105 ILCS 128 et seq.)
This school conducted, at a minimum, one annual review of each of its building’s emergency and crisis
response plans, protocols and procedures and each building’s compliance with the school safety drill programs.
For further information, see 105 ILCS 128 §§ 25 and 30(a).
Changes were made to this school’s response plans, protocols and procedures, as necessary, and these
changes have been forwarded to Illinois State Board of Education.
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