U.S. Department of Health and Human Services (HHS)
Agency for Healthcare Research and Quality (AHRQ)
Health Resources and Services Administration (HRSA)
States can administer this functionally downloadable questionnaire to their hospitals, and hospitals can self-administer the questionnaire to measure their own readiness. Hospitals and health care systems can use this questionnaire as an assessment and planning tool for chemical, biological, radiological, nuclear, and explosive events (CBRNE). Some hospitals may address events such as these as a component of an "all hazards plan."
Please note that AHRQ is not administering this questionnaire. Please do not send completed questionnaires or compiled data to AHRQ.
CBRNE is used throughout this questionnaire and is defined as follows: The release of a chemical, biological, radiological, nuclear, or explosive agent that threatens civilian populations.
Question responses should reflect the hospital's status at the time the questionnaire is filled out.
If you have any questions about the content of the questionnaire or technical difficulties with the Web-based instrument, please contact Sally J. Philips, R.N., Ph.D., Director, Public Health Emergency Preparedness Program, AHRQ at: Sally.Phillips@ahrq.hhs.gov.
Important: If it is not possible to fill in part of the questionnaire, log out, then complete it at a later time. Please click here to download a paper version of the questionnaire, and gather all the necessary information before entering information in the online version of the survey. Keep a completed copy for your records.
Download paper version of survey as a PDF file. If you do not have a PDF reader installed on your computer, you can download a free copy of the Adobe® Acrobat® Reader. This can open and print PDF files.
Hospital Name:_____________________________________________________________________
Street Address:_____________________________________________________________________
City: __________________________________ State: _____________________________________
Telephone Number:________________________ Zip (optional):______________________________
Primary Contact for this Survey: _______________________________________________________
Title of Primary Contact: _____________________________________________________________
Telephone Number of Primary Contact: _________________________________________________
E-mail Address of Primary Contact: ____________________________________________________
| (check all that apply) | (check most applicable) | (check most applicable) |
|---|---|---|
|
___ General medical, surgical ___ Burn center ___ Trauma center ___ Psychiatric ___ Children's ___ Long-term care/skilled nursing facility ___ Rehabilitation ___ Other |
___ Rural (non-Metropolitan Statistical Area) (MSA) hospital ___ Urban (MSA) hospital ___ Don't know |
___ Private for-profit ___ Private not-for-profit ___ Military ___ Veterans Administration ___ Indian Health Service ___ Other public (Federal, State, local government) ___ Other |
Is your hospital an academic/teaching facility?
___ Yes ___ No
Is your hospital in a network or system with other hospitals?
___ Yes ___ No
Number of Licensed Beds #__________ Number of Set Up and Staffed Beds #____________
If your hospital is a certified trauma center (American College of Surgeons [ACS] trauma center certified), please check the highest level of certification.
___ Level I
___ Level II
___ Level III
___ Level IV
___ State certified, but not ACS certified
___ Not trauma certified
Have HRSA National Bioterrorism Hospital Preparedness Program (NBHPP) funds been dispersed to your hospital from the State health department?
___ Yes ___ No ___ No, but have received other government funds (please list government funding agency) ____________________
Has your hospital received HRSA NBHPP "in-kind" resources from the State health department (e.g., equipment)?
___ Yes ___ No
1. Has the hospital designated a coordinator (or group/committee) who is responsible for overseeing all of the hospital's CBRNE preparedness efforts?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to designate a coordinator within the next 6 months.
___ Yes.
___ Other.
2. Has the hospital designated a medical director (or group) for its CBRNE preparedness efforts?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to designate a medical director within the next 6 months.
___ Yes.
___ Other.
3. Does the hospital use an Incident Command System (ICS) to manage events that impact normal operations?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to use an ICS within the next 6 months.
___ ICS is currently being developed.
___ Yes, but all hospital staff are not trained on their roles in the system.
___ Yes, and all hospital staff are trained on their roles in the system.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
Select the appropriate response for each National Incident Management System (NIMS) activity.
| Question | Response |
|---|---|
| Is the ICS used on a near daily basis to manage events that impact normal operations? | Y N |
| Is the ICS practiced routinely in exercises/drills? | Y N |
| Is the ICS updated as needed after exercises/drills? | Y N |
| Is the ICS incorporated into existing training programs? | Y N |
| Is the ICS formally incorporated into the emergency operations plan (EOP)? | Y N |
| Is the ICS coordinated with local entities? | Y N |
4. Has the hospital designated an individual to manage and maintain its decontamination capability?
___ No, and not planned within the next 6 months.
___ No, but planned within the next 6 months.
___ Yes, and their responsibilities include (check all that apply):
___ Inspecting, inventorying, storing, and purchasing personal protective equipment (PPE) when needed.
___ Upkeep and maintenance of the decontamination equipment.
___ Maintenance of training records.
___ Ongoing training.
___ Recruitment of new team members.
___ Maintenance of exposure records.
___ Other.
5. Does the hospital have a plan for a CBRNE event that is reviewed and updated?
___ No, and not planned within the next 6 months.
___ No, but the hospital intends to begin to draft a CBRNE plan within the next 6 months.
___ The plan is currently being drafted.
___ Yes, the plan includes the following but is not updated every 2 years.
___ Yes, the plan includes the following and is updated at least every 2 years.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
Select the appropriate response for each area of the plan:
| Question | Response |
|---|---|
| Hospital's roles and responsibilities in a community CBRNE event | Y N |
| Scenario in which the hospital itself is the target of a CBRNE event | Y N |
| Plan activation and staff notification procedures | Y N |
| Shelter in place | Y N |
| Evacuation | Y N |
| Initial recognition and presumptive diagnosis of symptomatic CBRNE patients | Y N |
| Communication to and notification of staff of suspected CBRNE cases | Y N |
| Diagnostic procedures or tests to make presumptive diagnosis | Y N |
| Means to access age-specific CBRNE medical management guidelines from the public health departments and other appropriate agencies | Y N |
| Provision of mental health services for affected patients | Y N |
| Provision for controlling hospital access to limit contamination of the facility and individuals | Y N |
| Capability to isolate CBRNE patients from general inpatient population | Y N |
| Capability to isolate CBRNE patients from general outpatient population | Y N |
| Provisions for handling suspected CBRNE agents brought to the hospital or sampled within the hospital | Y N |
| Patient care expansion areas usable for assessing and treating potential victims of CBRNE events | Y N |
| Memorandums of understanding with external treatment facilities for overflow in the event of treatment site contamination or capacity shortages | Y N |
| Receipt and management of surge caches of pharmaceuticals and supplies | Y N |
| Means to access additional supplies of blood and blood products | Y N |
| Follow up instructions for patients and their home care providers that consider published guidelines from public health departments or the Centers for Disease Control and Prevention (CDC) | Y N |
| Cost recovery plan coordinated with third party payers | Y N |
| After-action evaluation of hospital's response to CBRNE event | Y N |
| Disaster Recovery Procedures | Y N |
6. Are funds for CBRNE preparedness (i.e., planning, training, operations, etc.) included into the hospital's budget?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to include CBRNE preparedness funds into the budget within the next 6 months.
___ Budgetary items are currently being evaluated.
___ Yes, but only those received from NBHPP.
___ Yes, and there are funds over and above those received from NBHPP.
___ Other.
7. Does the hospital participate in a regional planning group (i.e., local/State public health department) or other groups responsible for regional CBRNE preparedness?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to participate in a regional planning group within the next 6 months.
___ Involvement in a regional planning group is being considered.
___ Yes, but there is relatively infrequent interaction between the regional planning group and the hospital.
___ Yes, and there is ongoing interaction between the regional planning group and the hospital.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
Select the appropriate response for participants in the regional planning activity:
| Question | Response |
|---|---|
| Hospitals in local area | Y N |
| Department of Homeland Security | Y N |
| Health department | Y N |
| Local emergency planning committee | Y N |
| Local fire department | Y N |
| Local emergency medical service(s) (EMS) | Y N |
| Local law enforcement | Y N |
| Other (please list) | Y N |
8. Does the hospital provide competency-based training on CBRNE events to clinical staff?
___ No, and not planned within the next 6 months.
___ No, but hospital plans to provide competency-based training to clinical staff within the next 6 months.
___ Some clinical staff have been trained.
___ Yes, all clinical staff have been trained, but less frequently than every 2 years.
___ Yes, all clinical staff are trained at least every 2 years.
___ Other.
9. Does the hospital provide competency-based training on CBRNE events to non-clinical staff?
___ No, and not planned within the next 6 months.
___ No, but hospital plans to provide competency-based training to non-clinical staff within the next 6 months.
___ Some non-clinical staff have been trained.
___ Yes, all non-clinical staff have been trained, but less frequently than every 2 years.
___ Yes, all non-clinical staff are trained at least every 2 years.
___ Other.
10. Does the hospital provide training in accordance with Occupational Safety and Health Administration (OSHA) standards to personnel who may be part of the decontamination response?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to provide training according to OSHA standards within the next 6 months.
___ Training curriculum is currently being developed.
___ Yes, training on the following is provided, but not on an annual basis.
___ Yes, and training on the following is provided annually.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
| Type of Training | Conducted Training | Tested in Exercise/Drill |
|---|---|---|
| OSHA-level operations training for all staff with designated roles in the hospital decontamination zone (area where contamination may be found and decontamination performed) | Y N | Y N |
| OSHA-level awareness training for all staff assigned to areas proximate to the decontamination zone where contact with contaminated may occur | Y N | Y N |
| Agent identification | Y N | Y N |
| Selection and use of PPE | Y N | Y N |
| Decontamination area setup | Y N | Y N |
| Patient decontamination | Y N | Y N |
| Decontamination area cleanup | Y N | Y N |
| Radiation contamination/exposure management | Y N | Y N |
| Equipment inspection, maintenance, and storage | Y N | Y N |
11. Have persons designated in the hospital's CBRNE/all hazards plan received training on the regional emergency planning group's CBRNE response plan?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to provide training to persons designated in the hospital's CBRNE/all hazard plan within the next 6 months.
___ Training is currently underway.
___ Yes, but information from the training has not yet been incorporated into the hospital's CBRNE response plan.
___ Yes, and information from the training has been incorporated into the hospital's CBRNE response plan.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
| Designee | Trained |
|---|---|
| Infection control practitioner | Y N |
| Radiation safety officer | Y N |
| Mental health professional | Y N |
| Safety officer | Y N |
| Emergency department representative | Y N |
| Other | Y N |
12. Do staff members participate in hospital-wide and/or regional CBRNE event exercises/drills?
___ No, and not planned within the next 6 months.
___ No, but hospital plans to have staff members participate in a CBRNE event exercise/drill within the next 6 months.
___ Exercise/drill is being developed.
___ Yes, but not every 2 years.
Was the hospital's CBRNE/all hazards plan revised as a result of the exercise/drill?
___ Yes
___ No
___ Yes, at least every 2 years.
Was the hospital's CBRNE/all hazards plan revised as a result of the exercise/drill?
___ Yes
___ No
___ Other
13. Is a mechanism in place for the rapid receipt and posting of public health alerts during a CBRNE event from agencies such as Public Health, poison control, Health Alert Network, Centers for Disease Control and Prevention (CDC), etc.?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to put a mechanism in place for receiving and posting public health alerts within the next 6 months.
___ A formal process is currently being developed.
___ Yes, but only in the emergency department and infection control.
___ Yes, and they are made readily available throughout the clinical areas of the hospital.
___ Other.
14. Does the hospital have a dedicated system for staff information and call-in inquiries during a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to establish a dedicated system for use during a CBRNE event within the next 6 months.
___ A dedicated system is currently being developed.
___ Yes, but the system includes only phone access.
___ Yes, and the system includes multiple methods of access.
___ Other.
15. Does the Emergency Department have Internet access located in the department?
___ No, and not planned within the next 6 months.
___ No, but the emergency department plans to acquire Internet access within the next 6 months.
___ Internet access is located in another department.
___ Yes, but the connection requires a dial-up modem.
___ Yes, and the Internet is accessed by a high-speed connection.
___ Other.
16. Is the hospital a participant in a regional system to monitor Emergency Department diversion status?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to participate in a regional system to monitor Emergency Department diversion status within the next 6 months.
___ Regional system is currently being developed.
___ Yes, but the diversion status system is not monitored in real-time.
___ Yes, and the diversion status system is monitored in real-time.
___ Other.
17. Does the hospital's CBRNE/all hazards plan designate a position or individual (such as a Public Information Officer) to communicate about a CBRNE event to the media?
___ No, and not planned within the next 6 months.
___ No, but planned within the next 6 months.
___ Yes.
___ Other.
18. Are protocols in place for the release of information regarding the number of CBRNE casualties to the appropriate external agencies?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop protocols to release information to appropriate external agencies regarding the number of CBRNE casualties within the next 6 months.
___ Protocols are currently being developed.
___ Yes, but protocols have not yet been coordinated with appropriate external agencies.
___ Yes, and protocols have been coordinated with appropriate external agencies.
___ Other.
19. Does the hospital's CBRNE/all hazards plan address procedures that staff should follow in reporting a suspected CBRNE event to the appropriate external agencies?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop procedures for reporting a suspected CBRNE event within the next 6 months.
___ Procedures are under development.
___ Yes, but the procedures have not been communicated to the staff.
___ Yes, and the procedures have been communicated to the staff.
___ Other.
20. Is there a procedure in place for providing patient tracking (from initial triage to hospital admission or discharge)?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop a procedure for patient tracking within the next 6 months.
___ Procedure is currently being developed.
___ Yes, but procedure has not yet been tested with exercise/drill(s).
___ Yes, and procedure has been tested with exercise/drill(s).
___ Other
21. Is the hospital a participant in a regional system to monitor bed availability?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to participate in a regional system to monitor bed availability within the next 6 months.
___ Regional system is currently being developed.
___ Yes, but inpatient bed availability is not monitored in real-time.
___ Yes, and inpatient bed availability is monitored in real-time.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
Select the appropriate response for bed types being monitored:
| Question | Response |
|---|---|
| Inpatient | Y N |
| Intensive care unit(s) | Y N |
| Emergency department | Y N |
| Outpatient units | Y N |
22. Does the hospital's CBRNE/all hazards plan address policies and procedures for increasing inpatient bed capacity?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop policies and procedures to increase inpatient bed capacity within the next 6 months.
___ Policies and procedures are currently being developed.
___ Yes, policies and procedures are in place for the following areas:
___ Other.
(This table will be activated when the respondent selects #4 .)
| Types of Policies/Procedures | Included in Plan |
Tested In Exercise/Drill |
Additional Staffed Beds |
|---|---|---|---|
| Adult critical care | Y N | Y N | # |
| Adult medical | Y N | Y N | # |
| Adult surgical | Y N | Y N | # |
| Adult burns | Y N | Y N | # |
| Adult trauma | Y N | Y N | # |
| Pediatric critical care | Y N | Y N | # |
| Pediatric medical | Y N | Y N | # |
| Pediatric surgical | Y N | Y N | # |
| Pediatric burn | Y N | Y N | # |
| Pediatric trauma | Y N | Y N | # |
23. Does the hospital's CBRNE/all hazards plan address alternative treatment sites to serve patients during a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital will be developing a plan to address alternative treatment sites during a CBRNE event within the next 6 months.
___ Plan currently being developed.
___ Yes, but plan has not yet been tested with exercise/drill(s).
___ Yes, and plan has been tested with exercise/drill(s).
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
| Alternative Treatment Site | Included in Plan |
Tested in Exercise/Drill |
|---|---|---|
| Emergency department (ED) overflow | Y N | Y N |
| Alternative site if ED is contaminated | Y N | Y N |
| Isolation area adjacent to ED | Y N | Y N |
| Inpatient overflow | Y N | Y N |
| Outpatient overflow | Y N | Y N |
24. Does the hospital have protocols or memoranda of understanding (MOUs) in place with other area treatment facilities (e.g., hospitals, ambulatory care centers, extended care facilities) to transfer patients as a result of a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop protocols and MOUs to transfer patients as a result of a CBRNE event within the next 6 months.
___ Protocols or MOUs are currently being developed.
___ Yes, but have not yet been tested with exercise/drill(s).
___ Yes, and have been tested with exercise/drill(s).
___ Other.
25. Does the hospital have procedures that allow morgue capacity to be increased in case of mass fatalities?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop procedures to increase morgue capacity during a CBRNE event within the next 6 months.
___ Procedures are currently being developed.
___ Yes, but the procedures have not been tested with an exercise/drill.
___ Yes, the morgue capacity can be increased and the procedures have been tested with an exercise/drill.
___ Other.
26. Does the hospital's CBRNE/all hazards plan address procedures for expanding staff availability (e.g., callback lists, policies for overtime, staffing centers, etc.) during a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital will be developing a plan to expand staff availability during a CBRNE event within the next 6 months.
___ Plan to expand staff availability currently being developed.
___ Yes, plan includes procedures in the following areas but has not been tested in any area:
___ Yes, and procedures include expanding staff in the following areas and those procedures have been tested in the following areas:
___ Other.
(This table will be activated when the respondent selects #4 or #5. The "Tested in Exercise/Drill" column will not be activated if the respondent selects #4.)
| Areas Addressed in Staff Expansion Plan | Included in Plan |
Tested in Exercise/Drill |
|---|---|---|
| Emergency department | Y N | Y N |
| Critical care | Y N | Y N |
| Medicine/surgery | Y N | Y N |
| Pediatrics | Y N | Y N |
| Laboratory | Y N | Y N |
| Housekeeping | Y N | Y N |
| Pharmacy | Y N | Y N |
| Security | Y N | Y N |
| Food service | Y N | Y N |
| Respiratory therapy | Y N | Y N |
| Burn care | Y N | Y N |
| Trauma | Y N | Y N |
| Radiology | Y N | Y N |
| Types of Mechanisms | ||
| Callback lists | Y N | Y N |
| Policies for overtime | Y N | Y N |
| Staffing centers | Y N | Y N |
| Professional volunteers (pre-credentialed) | Y N | Y N |
27. Does the hospital have policies for the advance registration and credentialing of clinicians needed to augment hospital staff in case of a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to create policies for advance registration and credentialing of clinicians within the next 6 months.
___ Policies are currently being developed.
___ Yes, hospital has these policies.
___ Other.
28. Does the hospital have provisions for temporary housing and feeding personnel when needed during a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to develop provisions to temporarily house and feed personnel during a CBRNE event within the next 6 months.
___ Provisions are currently being developed.
___ Yes, but capacity is fixed.
___ Yes, and capacity can be expanded.
___ Other.
(This table will be activated when the respondent selects #4 or #5.)
Please select the appropriate response:
| Type | Response |
|---|---|
| For patients | Y N |
| For staff | Y N |
| For staffs' families | Y N |
29. Is mental health support available as a component of the care provided to staff in a CBRNE event?
___ No, and not planned within the next 6 months.
___ No, but the hospital plans to make mental health support available as a component of care to staff members in a CBRNE event within the next 6 months.
___ Capacity for support is being developed.
___ Yes, but support is not available 24 hours a day.
___ Yes, and support is available 24 hours a day.
___ Other.