Modules and Addenda
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Contents
Pre-Drill Module
Incident Command Center Zone Module
Decontamination Zone Module
Triage Zone Module
Treatment Zone Module
Biological Incident Addendum
Radiological Incident Addendum
Group Debriefing Module
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Pre-drill Module
Note: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable
Background Information
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
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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): _________________________________________________________
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1.c Will the drill include decontamination? Y / N / U
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2. Level and Scope of the Hospital Drill Activity
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.)
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2.c What are the specific objectives for the disaster drill? (Please limit to one sentence each.)
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3. Drill Activity
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. Incident Command
4.a Will there be an incident command center? (Check one.)
___ Yes If yes, where is its location? ___________________________________________
___ No |
5. Communications
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): _________________________________________________________
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6. Evaluation
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
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___ 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 |
Return to Contents
Incident Command Center Zone Module
Note: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable
Observer: _________________________________________ Date: ____/____/_______
Observer title: ____________________________________________________________
Hospital: ________________________________________________________________
Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.) |
1. Time Points
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.) |
2. Personnel
2a. Was an incident command system established? Y / N / U Comments:
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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. |
Functional Role |
A. Function Filled |
B. Comments |
2d. Incident Commander |
Y / N / U / NA |
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2e. Logistics Chief (oversees facilities, communications, patient transportation, and supplies) |
Y / N / U / NA |
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2f. Planning Chief (oversees staffing) |
Y / N / U / NA |
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2g. Operations Chief (oversees patient care, ancillary services, and staff support) |
Y / N / U / NA |
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2h. Other (specify): ____________________________ |
Y / N / U / NA |
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3. Zone Operations
3a. Did the incident command center function efficiently? Y / N / U
Comments: |
3b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan |
3c. 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):_________________________________
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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): __________________________________
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4. Communications
4a. Were communications effective? Y / N / U
Comments: |
Were the following communications devices used in the drill for internal or external communications? (Check all that apply.) |
Communications Device |
A. Internal |
B. External |
C. Comments (Note strengths and weaknesses.) |
4b. 2-way radio/phone(s) |
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4c. Landline phone(s) |
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4d. Wireless/cell phone(s) |
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4e. Personal data assistant(s) (PDA) |
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4f. Numeric paging |
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4g. Overhead paging |
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4h. Text paging |
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4i. E-mail/Internet access/network |
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4j. Fax machine(s) |
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4k. Intercom |
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4l. Megaphone(s) |
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4m. Runner(s) |
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4n. Satellite phone(s) |
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4o. Ham Radio |
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4p. Emergency radio |
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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): _________________________ |
5. Information Flow
5a. Was necessary information received? Y / N / U
Comments:
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5b. Did the incident command center receive timely updates regarding the total number of expected victims? Y / N / U |
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. |
6. Security
6a. Were entrances and exits strictly controlled in this area? Y / N / U
Comments:
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7. Rotation of Staff
7a. Were incoming staff updated? Y / N / U Comments: (If comment refers to a specific item, give the item number):
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Decontamination Zone Module
Note: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable
Observer: _________________________________________ Date: ____/____/_______
Observer title: ____________________________________________________________
Hospital: ________________________________________________________________
Period of time of evaluation: ______ AM/PM (Circle one.) to _____ AM/PM (Circle one.) |
1. Time Points
1a. Did the drill start on time? Y / N / U
Comments:
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1b. Time the drill began: (Circle one.) ______ AM / PM / U |
1c. Time this zone was ready to accept victims: (Circle one.) ______ AM / PM / U |
Zone Description
2a. Were the zone boundaries clearly defined? Y / N / U
Comments:
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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): _________________ |
3. Personnel
3a. Did someone assume command of this zone? Y / N / U
Comments:
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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. |
4. Zone Operations
4a. Did the decontamination area operations function efficiently? Y / N / U
Comments:
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4b. Was the decontamination zone set up prior to the arrival of first victim? Y / N / U |
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): ____________________________________________________________
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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. |
5. Victim Documentation and Tracking:
5a. Were all incoming victims registered and given a unique identification or medical record number? Y / N / U
Comments:
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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 |
6. Communications
6a. Were communications effective? Y / N / U
Comments:
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Were the following communications devices used in the drill for communication? (Check all that apply.) |
Communications Device |
A. Used |
B. Comments (Note strengths and weaknesses.) |
6b. 2-way radio/phone(s) |
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6c. Intercom |
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6d. Megaphone(s) |
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6e. Runner(s) |
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6f. Cell phones |
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6g. Text paging |
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6h. Fax machine(s) |
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6i. Personal data assistant(s) (PDA) |
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6j. E-mail/Internet/network |
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6k. Numeric paging |
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6l. Emergency radio |
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6m. Ham radio |
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6n. Landline phone(s) |
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6o. Satellite phone(s) |
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6p. Overhead paging |
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6q. Other (specify): _______________ |
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7. Information Flow
7a. Was necessary information received? Y / N / U
Comments:
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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 |
8. Security
8a. Were entrances and exits strictly controlled in this area? Y / N / U
Comments:
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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): _____________________________________________
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8c. Were security personnel present in this zone? Y / N / U |
9. Personal Protective Equipment (PPE) and Safety:
9a. Was an appropriate supply of PPE available? Y / N / U
Comments:
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9b. Was the PPE applied correctly? Y / N / U
Comments:
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9c. Was staffing of the decontamination zone adequate? Y / N / U
Comments:
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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. |
Safety material |
A. Available |
B. Used by staff? |
C. Adequate supply? |
9d. Protective suit |
Y / N / U |
Y / N / U |
Y / N / U |
9e. Hoods |
Y / N / U |
Y / N / U |
Y / N / U |
9f. Boots |
Y / N / U |
Y / N / U |
Y / N / U |
9g. Gloves, chemical resistant |
Y / N / U |
Y / N / U |
Y / N / U |
9h. Apron |
Y / N / U |
Y / N / U |
Y / N / U |
9i. Masks |
Y / N / U |
Y / N / U |
Y / N / U |
9j. Respirators (e.g., powered air purifying respirator) |
Y / N / U |
Y / N / U |
Y / N / U |
9k. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
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9l. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U |
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): _________________________________________________________ |
9n. Were all workers in the decontamination area dressed in appropriate PPE? Y / N / U |
9o. Was there inadvertent contamination of staff or victims? Y / N / U |
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): _______________________________
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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
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10. Zone Disruption
10a. Did the zone function as planned? Y / N / U
Comments:
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10b. Was there a plan in place to relocate this zone if necessary? Y / N / U |
Comments (If comment refers to a specific item, give the item number.): |
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