Observer: _________________________________________   Date: ____/____/_______

Observer title: ____________________________________________________________

Hospital: ________________________________________________________________

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

Were the following informed that a biological agent may be involved?

If not informed, circle "N" in column "A" and go to the next line.

3b. If the cause of the illness was not known prior to victim arrival, how long after the first victim arrived was the cause of the illness identified? (Check one.)

___ < 1 hr      ___ 1 - 4 hrs                 ___ 5 - 8 hrs

___ > 8 hrs   ___ Never identified    ___ NA

3c. What was the cause of the illness? (Check all that apply.)

a. ___ Anthrax                            b. ___ Botulinum toxin

c. ___ Plague                             d. ___ Influenza

e. ___ Smallpox                         f. ___ Tularemia

g. ___ Viral hemorrhagic fever   h. ___ Unknown

i. ___ Other (specify): _____________________________________________________________

3d. What resources were used to make the diagnosis(es)? (Check all that apply.)

a. ___ Consultation with an in-hospital expert

b. ___ Consultation with an expert from state/local health department

c. ___ Consultation with the Centers for Disease Control and Prevention (CDC)

d. ___ History and physical exam by the treating health care provider

e. ___ Microbiological data

f. ___ Radiologic data

g.___ Telemedicine

h.___ NA

i. ___ Other (specify): _____________________________________________________

4a. Was isolation required for the suspected illness involved?   Y / N / U

Isolation required for smallpox, plague, viral hemorrhagic fever, certain pneumonias or rashes, and other symptoms suggestive of a contagious infection outbreak.

If no isolation was required, skip to the Screening and Prophylaxis section.

4b. Were there delays in placing victims in isolation rooms?    Y / N / U

If there were delays, specify in comment box at the end of this module.

4d. If insufficient isolation rooms, how were victims isolated? (Check all that apply.)

a. ___ Conversion of other rooms/area (specify): _________________________________

b. ___ Existing isolation room in other area (specify): _____________________________

c. ___ Overflow victims not isolated

d. ___ Victims with the same suspected illness caused by a biological agent placed in the same isolation room

e. ___ NA

f. ___ Other (specify): ______________________________________________________

4f. Were any breaches in isolation precautions identified?   Y / N / U

If there were any breaches in the isolation precautions, specify in comment box at end of this module.

5a. Given the suspected illness caused by a biological agent, was PPE used to protect healthcare workers?   Y / N / U

Isolation required for smallpox, plague, viral hemorrhagic fever, certain pneumonias or rashes, and other symptoms suggestive of a contagious infectious outbreak.

Y / N / U

Observer: _________________________________________   Date: ____/____/_______

Observer title: ____________________________________________________________

Hospital: ________________________________________________________________

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

2a. How did this zone become aware that radiological victims were involved? (Check all that apply.)

a. ___ Informed by fire department   b. ___ Informed by incident command center

c. ___ Onsite alarm                           d. ___ Other (specify): _________________________

Were the following informed that a radiological agent may be involved?

If not informed, circle "N" in column "A" and go to the next line.

5h. Were breaches in precautions observed?          Y / N / U

If breaches in precautions were observed, specify in comment box at end of this module.

If needed, were these safety materials available for the healthcare workers?

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