1.a Name of person completing module: ____________________________________________

Title: ________________________________________________________________________

Office phone: _________________________________________________________________

Hospital: _____________________________________________________________________

Cell phone: ___________________________________________________________________

Room number: ________________________________________________________________

E-mail: ______________________________________________________________________

Street address: ________________________________________________________________

Fax: _________________________________________________________________________

City and state: _________________________________________________________________

Pager: _______________________________________________________________________

Best method of contact during the drill. (Circle one.)
Cell phone  E-mail  Fax  Office phone  Pager

1.b. What will the disaster scenario include? (Check all that apply.)

___ Biological agent                                 ___ Chemical agent

___ Fire                                                     ___ Incendiary device/explosive

___ Natural disaster (e.g., earthquake)   ___ Radiological agent

___ Structural collapse                             ___ Transportation accident

___ Internal hospital system failure (specify): _____________________________________

___ Other (specify): _________________________________________________________

1.c Will the drill include decontamination?     Y / N / U

2.a What type of disaster drill is your hospital performing? (Check one.)

___ Operationalized drill

___ Tabletop Exercise

___ Computer Simulation

___ Other (specify): _________________________________________________________

2.b. What is your main overall goal for the disaster drill? (Please limit to one sentence and include previous after-action items as appropriate.)

2.c What are the specific objectives for the disaster drill? (Please limit to one sentence each.)

3.a How will the notification to initiate the drill occur? (Check all that apply.)

___ By another hospital       ___ By first victim arrival

___ By health department   ___ By government agency (e.g., federal or state emergency agency)

___ EMS dispatch center

___ Other (specify): ___________________________________________________________

3.b Which hospital personnel (not including victims or observers) from the following staff groups will actively participate in the drill activities? (Check all that apply.)

___ Administration

___ Engineering and physical plant

___ Laboratory

___ Occupational health

___ Radiation safety

___ Social work

___ Pediatrics department

___ Surgery department

___ Central supply

___ Infection control

___ Medical staff

___ Pharmacy

___ Safety

___ Emergency department

___ Psychiatry department

___ Hospital-wide

___ EMS/patient transport service

___ Intensive care unit

___ Nursing

___ Public affairs

___ Security

___ Medicine department

___ Radiology department

___ Other (specify): _________________________________________________________

___ Other (specify): _________________________________________________________

3.c What levels of activity will be included in the drill? (Check all that apply.)

___ Materials and supplies received

___ Triage of victims

___ Simulated clinical procedures performed

___ Victim decontamination

___ Victim transport in the emergency department only

___ Victim transport throughout hospital

___ Other (specify): _________________________________________________________

3.d What other organizations/agencies will be involved in the drill? (Check all that apply.)

___ Ambulance system   ___ Hospital/health systems(s) (specify): ____________________

___ Fire                            ___ City/local agency(ies) (specify): ________________________

___ Media                        ___ State agency(ies) (specify): ___________________________

___ Police                        ___ Federal agency(ies) (specify): _________________________

___ Military (specify): _______________________________________________________

___ Other (specify): ________________________________________________________

4.a Will there be an incident command center? (Check one.)

___ Yes   If yes, where is its location? ___________________________________________

___ No

5.a What methods will personnel use to communicate during the drill? (Check all that apply.)

___ 2-way radio/phone(s)

___ Fax machine(s)

___ Megaphone(s)

___ PDA(s)

___ Text paging

___ E-mail/Internet/network

___ Intercom

___ Numeric paging

___ Runner(s)

___ Wireless/cell phone(s)

___ Emergency radio

___ Landline phone(s)

___ Overhead paging

___ Satellite phone(s)

___ Ham radio

___ Other (specify): _________________________________________________________

6.a Which aspects do you plan to evaluate during the disaster drill? (Check all that apply.)

___ Decontamination

___ Treatment

___ Biological illness exposure

___ Communication and information flow

___ Facility engineering

___ Patient flow

___ Radiation exposure

___ Security

___ Surge capacity

___ Zone disruption

___ Incident command

___ Triage

___ Chemical exposure

___ Equipment and supplies

___ Patient documentation and tracking

___ Personal protective equipment (PPE) use

___ Rotation of staff

___ Staffing

___ Time points

___ Zone operations

___ Other (specify): _________________________________________________________

6.b Name of lead person, if different than 1.a, planning to conduct the debriefing session:

__________________________________________________________________________

Title: ______________________________________________________________________

Office phone: _______________________________________________________________

Hospital: __________________________________________________________________

Cell phone: ________________________________________________________________

Room number: _____________________________________________________________

Street address: _____________________________________________________________

Fax: ______________________________________________________________________

City and state: ______________________________________________________________

Pager: ____________________________________________________________________

Best method of contact during the drill. (Check one.)

___ Cell phone    ___ E-mail   ___ Fax   ___ Office phone   ___ Pager

Observer: _________________________________________   Date: ____/____/_______

Observer title: ____________________________________________________________

Hospital: ________________________________________________________________

Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.)

1a. Did the drill start on time?   Y / N / U

Comments:

1b. Time the drill began: (Circle one.)   ______ AM / PM / U

1c. Time the hospital disaster plan was initiated in this zone:   ______ AM / PM / U / Not initiated
(Circle one.)

2a. Was an incident command system established?   Y / N / U

Comments:

2b. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (Check one.)

___ <10 min    ___ 10 - 29 min    ___ 30 - 59 min

___ 1 - 2 hrs    ___>2 hrs             ___NA

___ No one took charge.

2c. Were the following drill participants identifiable?

a. Incident Commander Y / N / U / NA   b. Incident Command Personnel Y / N / U / NA

c. Drill Evaluators Y / N / U / NA            d. Drill Organizers Y / N / U / NA

e. Security Y / N / U / NA

Was someone fulfilling the functions of the following roles (within the incident command center or elsewhere) or reporting to the incident command center?

If no one fulfilled a specified function, circle "N" in column "A" and go to the next row.

3a. Did the incident command center function efficiently?    Y / N / U

Comments:

a. ___ Not available              b. ___ Too complex

c. ___ Not relevant to drill    d. ___ Participants unfamiliar with plan

e. ___ Too hard to access    f. ___ Other (specify):_________________________________

3d. If the hospital disaster plan was available, what was its format? (Check all that apply.)

a. ___ Complete manual   b. ___ Flow diagram   c. ___ Job action sheets

d. ___ No disaster plan     e. ___ Other (specify): __________________________________

4a. Were communications effective?   Y / N / U

Comments:

4q. How was incoming information to the zone recorded? (Check all that apply.)

a. ___ Computer (or other electronic device)   b. ___ Notepaper

c. ___ Posted paper                                         d. ___ White board/chalk board

e. ___ Not recorded                                         f. ___ Other (specify): _________________________

5a. Was necessary information received?   Y / N / U

Comments:

5c. Were problems created by delays in receiving information?   Y / N / U

If problems were created by delays in information, specify in comment box at end of this module.

6a. Were entrances and exits strictly controlled in this area?   Y / N / U

Comments:

7a. Were incoming staff updated?   Y / N / U

Comments: (If comment refers to a specific item, give the item number):

Observer: _________________________________________   Date: ____/____/_______

Observer title: ____________________________________________________________

Hospital: ________________________________________________________________

Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.)

1a. Did the drill start on time?   Y / N / U

Comments:

2a. Were the zone boundaries clearly defined?   Y / N / U

Comments:

2b. How was the boundary for this zone defined? (Check all that apply.)

a. ___ Barricade(s)   b. ___ Sign(s)             c. ___ Tape

d. ___ Wall(s)            e. ___ No boundary    f. ___ Other (specify): _________________

3a. Did someone assume command of this zone?   Y / N / U

Comments:

3b. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (Check one.)

___ <10 min    ___ 10 - 29 min    ___ 30 - 59 min

___ 1 - 2 hrs    ___>2 hrs             ___NA

___ No one took charge.

4a. Did the decontamination area operations function efficiently?    Y / N / U

Comments:

4c. Were there problems with decontamination of non-ambulatory victims?

___ Yes   ___ No   ___ No non-ambulatory victims   ___ Unclear

4d. Were victims' clothing and personal belongings removed during decontamination?    Y / N / U

4e. Were victims' clothing and personal belongings marked as hazardous and secured?

Y / N / U

4f. Mechanism of decontamination? (Check all that apply and estimate the number.)

a. ___ EMS or fire department vehicles with hoses (number: _______)

b. ___ Permanent overhead showers/sprinklers (number: _______)

c. ___ Temporary decontamination tent(s) (number: _______)

d. ___ Indoor decontamination facilities (number: _______)

e. ___ Other (specify): ____________________________________________________________

4g. Was medical oversight of victims maintained through the decontamination process?

Y / N / U

4h. Did a bottleneck develop in this zone?    Y / N / U

If a bottleneck did develop, describe in the comment box at the end of this module.

5a. Were all incoming victims registered and given a unique identification or medical record number?   Y / N / U

Comments:

5b. When were incoming victims registered and given a unique identification or medical record number? (Check one.)

___ Before entering this zone   ___ On entering this zone

___ Not while in this zone         ___ Unclear

6a. Were communications effective?   Y / N / U

Comments:

7a. Was necessary information received?   Y / N / U

Comments:

7b. Were problems created by delays in receiving information?   Y / N / U

If problems were created by delays in information, specify in comment box at end of this module.

7c. When was your zone made aware of the potential involvement of a chemical or radiological agent? (Check one.)

___ Before the first victim arrived                  ___ After first victim arrived

___ All victims completed decontamination   ___ Never made aware

___ Unsure

8a. Were entrances and exits strictly controlled in this area?   Y / N / U

Comments:

8b. Did any of the following security issues arise in this zone? (Check all that apply)

a. ___ Crowd control   b. ___ Media control

c. ___ Unruly victims   d. ___ Other (specify): _____________________________________________

9a. Was an appropriate supply of PPE available?   Y / N / U

Comments:

9b. Was the PPE applied correctly?   Y / N / U

Comments:

9c. Was staffing of the decontamination zone adequate?   Y / N / U

Comments:

If needed, were these items for standard precautions available for the healthcare workers?

If safety materials were not available, circle "N" in column "A" and go to the next row.

9m. If available, in what format were they? (Check all that apply).

a. ___ Verbal instructions by staff   b. ___ Poster(s)

c. ___ Written instruction(s)            d. ___ Video

e. ___ Other (specify): _________________________________________________________

9p. What issues with donning and removing PPE arose in this zone? (Check all that apply.)

a. ___ Broken seals                            b. ___ Delay in donning PPE                 c. ___ Improper fit

d. ___ Staff not trained to don PPE   e. ___ Staff not trained to remove PPE   f. ___ None

g. ___ Other (specify):_________________________________________________________

9q. What issues with staffing arose in this zone? (Check all that apply.)

a. ___ Could not communicate with each other      b. ___ Fatigue   c. ___ Over-heating/dehydration

d. ___ Inadequate numbers to allow work cycles   e. ___ Other (specify): _______________________________

9r. How were victims screened for appropriate decontamination prior to leaving the decontamination zone? (Check all that apply.)

a. ___ Screening device (e.g., radiation or chemical detector)

b. ___ Physical examination   c. ___ Not screened

10a. Did the zone function as planned?   Y / N / U

Comments: