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: