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. Was staffing for the triage zone adequate?   Y / N / U

Comments:

3c. 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.

3d. Were the following drill participants identifiable?

a. Person in charge  Y / N / U / NA     b. Drill evaluators  Y / N / U / NA

c. Drill organizers  Y / N / U / NA         d. Media  Y / N / U / NA

e. Medical personnel  Y / N / U / NA    f. Mock victims  Y / N / U / NA

g. Observers  Y / N / U / NA                 h. Security  Y / N / U / NA

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

Comments:

4c. If not followed, what were the reason(s)? (Check all that apply.)

a. ___ Not available              b. ___ Too complex

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

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

4d. 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): __________________________________

4e. Was the space allocated for the zone adequate?   Y / N / U

4f. If victims were screened for biological, chemical, or radiological exposure, how were they screened? (Check all that apply.)

a. ___ Personal interview   b. ___ Physical examination   c. ___ Screening device (e.g., radiation or chemical detector)

d. ___ Not screened          e. ___ NA                                  f. ___ Other (specify): ______________

4g. 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

5c. What was the method of documenting the victim record in this zone? (Check all that apply.)

a. ___ Computer entry       b. ___ Data card(s) attached to victims

c. ___ Scanner                   d. ___ Separate victim paper chart

e. ___ No documentation   f. ___ Other (specify): ________________________________

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

Comments:

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

Comments:

7c. How was this zone kept aware of the ongoing general situation within the hospital? (Check all that apply.)

___ Call from incident command                     ___ Fax from incident command

___ Other contact from incident command    ___ Runner(s) from incident command

___ Contact from other internal sources (specify): ________________________________

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:

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.

9k. 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): ___________________________

10a. Were there appropriate quantities of medical supplies?   Y / N / U

Comments:

Were these medical supplies available?

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

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. What type of unit is this zone during regular hospital functioning? (Check all that apply.)

a. ___ Emergency Department (ED)    b. ___ Intensive Care (ICU)

c. ___ Medical Inpatient                       d. ___ Medical Outpatient

e. ___ Surgical Inpatient                       f. ___ Surgical Outpatient

g. ___ Other (specify): _______________________________________________________

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

Comments:

3b. Was staffing of the treatment zone adequate?   Y / N / U

Comments:

3c. How many minutes after the drill activities in this zone commenced did someone 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.

3d. Were the following drill participants identifiable?

a. Drill evaluators  Y / N / U / NA   b. Drill organizers  Y / N / U / NA

c. Media  Y / N / U / NA                 d. Medical personnel  Y / N / U / NA

e. Mock victims  Y / N / U / NA       f. Observers  Y / N / U / NA

g. Security  Y / N / U / NA

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

Comments:

4c. If not followed, what were the reason(s)? (Check all that apply.)

a. ___ Not available            b. ___ Too complex

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

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

4d. 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): ____________________________________

4e. Was the space allocated for the zone adequate?   Y / N / U

If space allocated was not adequate, specify in comment box at end of this module.

4f. 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.

4g. How were victims managed who were not previously triaged? (Check one.)

___ Sent back to triage zone   ___ Sent to another area (specify): ________________________

___ Triaged in this zone           ___ Treated without being triaged

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

Comments:

5b. When were all 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

5c. What was the method of documenting the victim record in this zone? (Check all that apply.)

a. ___ Computer entry         b. ___ Data card(s) attached to victims

c. ___ Dictation system       d. ___ Personal data assistant (PDA)

e. ___ Scanner                   f. ___ Separate victim paper chart

g. ___ No documentation    h. ___ Expedited registration

i. ___ Other (specify): ________________________________

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

Comments:

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

Comments:

7c. How was this zone kept aware of the ongoing general situation within the hospital? (Check all that apply.)

a. ___ Call from incident command                   b. ___ Fax from incident command

c. ___ Other contact from incident command    d. ___ Runner(s) from incident command

e. ___ Contact from other internal sources (specify): _________________________________________

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:

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

9k. 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): ____________________________

10a. Were there appropriate quantities of medical supplies?   Y / N / U

Comments:

Were needed medical supplies available?

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