Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
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Main Spreadsheet
These evaluation forms are designed to help hospitals compile responses from the modules and compare data.
Pre-Drill Module / Main Module / Biological Incident Addendum / Radiological Incident Addendum
| Hospital |
# |
Question |
Incident Command Center |
Decontamination |
Triage |
Treatment |
| Section |
| Observer Information |
|
Date |
|
|
|
|
| Observer name |
|
|
|
|
| Observer title |
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|
|
|
| Time period of evaluation |
|
|
|
|
| |
10 triage |
|
|
|
|
| |
20 triage |
|
|
|
|
| |
NA |
|
|
|
|
| Time Points |
C1 |
Drill began |
|
|
|
|
| C2 |
Disaster plan initiated in zone |
|
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|
|
| C3 |
Time this zone was ready to accept victims |
|
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|
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| C4 |
Time zone notified that ICC operational |
|
|
|
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| C5 |
Drill ended in zone |
|
|
|
|
| DE1 |
Time 1st victim arrived at decon zone |
|
|
|
|
| TG1 |
Time 1st victim arrived at triage zone |
|
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| TX1 |
Time 1st victim arrived in treatment zone |
|
|
|
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| |
Comments: |
|
|
|
|
| Zone Description |
C6 |
Picture of zone setup |
|
|
|
|
| C7 |
Zone location |
a. Ambulance ramp |
|
|
|
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| b. Inside the hospital |
|
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|
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| c. Parking lot |
|
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|
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| d. Street/road |
|
|
|
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| e. Other (specify) |
|
|
|
|
| C8 |
Boundary for zone defined? |
Y / N / U |
|
|
|
|
| C9 |
How defined |
a. Barricade(s) |
|
|
|
|
| b. Security personnel |
|
|
|
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| c. Sign(s) |
|
|
|
|
| d. Tape |
|
|
|
|
| e. Vehicle(s) |
|
|
|
|
| f. Wall(s), permanent |
|
|
|
|
| g. Wall(s),
temporary |
|
|
|
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| h. No boundary |
|
|
|
|
| i. Other (specify) |
|
|
|
|
| C10 |
Were providers able to move easily through this zone? |
Y / N / U |
|
|
|
|
| DE2 |
Type area used for decon |
a. Covered designated outdoor decon area |
|
|
|
|
| b. Open outdoor decon area |
|
|
|
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| c. Designated indoor decon area; specify
# rooms |
|
|
|
|
| d. Other (specify) |
|
|
|
|
| DE3 |
Distance EMS offload to decon area (ft) |
|
|
|
|
| TG2 |
Triage zone contiguous to or located in emergency
department (ED) |
Y / N / U |
|
|
|
|
| TG3 |
Distance away if not contiguous (ft) |
|
|
|
|
| TX2 |
Type of unit during day to day activities |
a. ED |
|
|
|
|
| b. Intensive care |
|
|
|
|
| c. Medical inpatient |
|
|
|
|
| d. Medical outpatient |
|
|
|
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| e. Surgical inpatient |
|
|
|
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| f. Surgical outpatient |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| TX3 |
Location of unit (e.g. floor) |
|
|
|
|
| TX4 |
Actual patients treated in drill treatment area |
Y / N / U |
|
|
|
|
| |
Comments: |
|
|
|
|
| Personnel |
C11 |
Someone in charge of zone? |
Y / N / U |
|
|
|
|
| C12 |
Minutes after drill activity began in zone that person took charge |
<10 min |
|
|
|
|
| 10-29 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| No one |
|
|
|
|
| C13 |
Officially designated person? |
Y / N / U / NA |
|
|
|
|
| C14 |
How person in charge of zone identified |
a. Arm band |
|
|
|
|
| b. Hat |
|
|
|
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| c. Name tag |
|
|
|
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| d. Verbal statement |
|
|
|
|
| e. Vest |
|
|
|
|
| f. Not identified |
|
|
|
|
| g. Other physical identification (specify) |
|
|
|
|
| C15 |
Drill participants identifiable |
Drill evaluators |
|
|
|
|
| b. Drill organizers |
|
|
|
|
| c. Media |
|
|
|
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| d. Medical personnel |
|
|
|
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| e. Mock victims |
|
|
|
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| f. Observers |
|
|
|
|
| g. Security |
|
|
|
|
| |
Number of hospital participants initially assigned to this zone? |
|
|
|
|
| C16 |
Physicians |
# |
|
|
|
|
| C17 |
Nurses |
# |
|
|
|
|
| C18 |
Ancillary personnel |
# |
|
|
|
|
| C19 |
Additional drill participants added? |
Y / N / U |
|
|
|
|
| |
Approximate number of additional staff |
|
|
|
|
| C20 |
Physicians |
# |
|
|
|
|
| C21 |
Nurses |
# |
|
|
|
|
| C22 |
Ancillary personnel |
# |
|
|
|
|
| IC1 |
First took charge of zone? (name and title) |
|
|
|
|
| IC2 |
Minutes after drill start that designated
incident commander arrived |
<10 min |
|
|
|
|
| 10-20 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Never arrived |
|
|
|
|
| IC3 |
Members of incident command identifiable? |
(Y / N / U) |
|
|
|
|
| |
Someone filling functions of following
roles or reporting to ICC? |
|
|
|
|
| IC4 |
Incident Commander |
Y / N / U / NA Comments |
|
|
|
|
| IC5 |
Public Information Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC6 |
Liaison Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC7 |
Safety and Security Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC8 |
Logistics Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC9 |
Facilities Management Unit |
Y / N / U / NA Comments |
|
|
|
|
| IC10 |
Communications Unit |
Y / N / U / NA Comments |
|
|
|
|
| IC11 |
Patient Transport Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC12 |
Material/Supply Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC13 |
Nutritional Supply Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC14 |
Planning Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC15 |
Labor Pool Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC16 |
Medical Staff Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC17 |
Nursing Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC18 |
Finance Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC19 |
Operations Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC20 |
Medical Care Director |
Y / N / U / NA Comments |
|
|
|
|
| IC21 |
Ancillary Services |
Y / N / U / NA Comments |
|
|
|
|
| IC22 |
Human Services Director |
Y / N / U / NA Comments |
|
|
|
|
| IC23 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| IC24 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| IC25 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| TG4 |
Anyone perform triage independently and without authority? |
Y / N / U |
|
|
|
|
| |
Comments: |
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