PD1. Name of person completing module: _____________________________________________________________

Title: _________________________________________           Office phone: _________________________________

Hospital: ______________________________________           Cell phone: __________________________________

Street address: _________________________________           Fax: _______________________________________

City and State: _________________________________           Pager: ______________________________________

Best method of contact during the drill. (Check one)

O Cell phone           O Fax           O E-mail           O Office phone           O Pager

PD2. Name of an additional contact person: ___________________________________________________________

Title: _________________________________________           Office phone: _________________________________

Hospital: ______________________________________           Cell phone: __________________________________

Street address: _________________________________           Fax: _______________________________________

City and State: _________________________________           Pager: ______________________________________

Best method of contact during the drill. (Check one)

O Cell phone           O Fax           O E-mail           O Office phone           O Pager

PD3. What will the disaster scenario include? (Check all that apply)

[  ] Biological           [  ] Chemical           [  ] Fire           [  ] Incendiary device/explosive

[  ] Natural disaster (e.g., earthquake)           [  ] Radiation           [  ] Structural collapse

[  ] Transportation accident           [  ] Internal hospital system failure (specify):

_____________________________________________________________________________

[  ] Other (specify):

_____________________________________________________________________________

PD4. Proposed date of drill:  month: ________________  date(s): ________________  year: ________________

PD5. Estimated start time of drill: _____________________ AM / PM (Circle one)

PD6. Expected length of drill:  number of hours: ___________________  number of days: ___________________

PD7. Will the disaster drill be announced to the staff prior to the beginning of the drill? (Check one)

O Yes           O No           O Unclear

PD8. What type of disaster drill is your hospital performing? (Check one)

O Operationalized drill
O Tabletop Exercise
O Computer Simulation
O Other (specify): _______________________________________________________________________________________________

PD9. What is your main overall goal for the disaster drill? (Please limit to one sentence)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

PD10. What are the specific objectives for the disaster drill? (Please limit to one sentence each)

a. ____________________________________________________________________________________________

b. ____________________________________________________________________________________________

c. ____________________________________________________________________________________________

d. ____________________________________________________________________________________________

PD11. How many mock victims will be included in the drill? (Enter approximate number)

Actual: _____________________ Paper: _____________________

PD12. If there will be mock victims, how will they be physically identified? (Check all that apply)

[  ] Bar coding           [  ] Clothing (shirts, caps, etc.)           [  ] Victim tracking cards

[  ] Wrist bands           [  ] NA           [  ] Other (specify): _____________________

PD13. Will the mock victims include people with medical training (i.e., "smart" casualties) who will assist in assessment of care received? (Check one)

O Yes    O No    O Unclear    O NA

PD14. If yes, specify the number of "smart" casualties: _____________________    O NA

PD15. How will the triage levels for mock victims be identified? (Check all that apply)

[  ] Color codes           [  ] Other (specify):__________________________________________

[  ] Number codes       [  ] Other (specify): __________________________________________

PD16. Where will the mock victims gather and prepare for the drill?

PD17. Where will the event that initiates the drill take place? (Check one)

[  ] < 1 mile
[  ] 1 - 5 miles
[  ] 6 - 10 miles
[  ] > 10 miles

PD18. 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)

[  ] Other (specify): _____________________________________________________________________

PD19. Which hospital personnel (not including victims or observers) from the following staff groups will actively participate in the drill activities? (Check all that apply)

PD20. What is the approximate total number of hospital personnel (not including victims or observers) participating in the drill? (Check one)

O <10
O 10 - 15
O 16 - 50
O 51 - 100
O 101 - 250
O > 250

PD21. What levels of activity will be included in the drill? (Check all that apply)

[  ] Materials and supplies received
[  ] Simulated clinical procedures performed
[  ] Triage of victims
[  ] Victim decontamination
[  ] Victim transport in the emergency department only
[  ] Victim transport throughout hospital
[  ] Other specify): ___________________________________________________________________________

PD22. Will activities occur in active patient care areas? (Check one)

O Yes    O No    O Unclear

PD23. What other organizations/agencies will be involved in the drill? (Check all that apply)

[  ] Ambulance system
[  ] Community
[  ] Fire
[  ] Media
[  ] Police
[  ] Hospital/health systems(s) (specify): ____________________________________
[  ] State agency (ies) (specify): ___________________________________________
[  ] Federal agency (specify): _____________________________________________
[  ] Military (specify): ____________________________________________________
[  ] Other (specify): ______________________________________________________

PD24. Does the hospital have any existing memorandums of understanding (MOUs) with outside agencies? (Check one)

O Yes    O No

PD25. If there are existing MOUs, which ones will be activated during the drill? (Check all that apply)

[  ] Ambulance system
[  ] Community
[  ] Fire
[  ] Media
[  ] Police
[  ] None
[  ] Hospital/health systems(s) (specify): ____________________________________
[  ] State agency (ies) (specify): ___________________________________________
[  ] Federal agency (specify): _____________________________________________
[  ] Military (specify): ____________________________________________________
[  ] Other (specify): ______________________________________________________

PD26. In what format is the disaster plan available to the hospital staff? (Check all that apply)

[  ] Complete manual
[  ] Flow diagram
[  ] Job action sheets

[  ] No disaster plan
[  ] Other specify): ___________________________________________________________________________

PD27.  Will there be an incident command center? (Check one)

O Yes       O No

If yes, where is its location? ________________________________________________________

PD28. If there will be no incident command center, describe how the drill will be managed in the hospital. (Please limit to one sentence)

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

PD29. Will the incident commander and other zone leaders be identified (e.g., by vest, armband, etc.)? (Check one)

O Yes  O No  O Unclear

PD30 If the incident commander and other functional leaders will be identified, what method of identification will be used? (Check all that apply)

[  ] Arm bands
[  ] Hats
[  ] Tee shirts
[  ] Vests
[  ] NA
[  ] Other (specify):___________________________________

PD31. What methods will personnel use to communicate during the drill? (Check all that apply)

[  ] 2-way radio/phone(s)
[  ] AM/FM radio(s)
[  ] E-mail and Internet access
[  ] Direct line(s)
[  ] Fax machine(s)
[  ] Intercom
[  ] Landline phone(s)
[  ] Megaphone(s)
[  ] Numeric paging
[  ] Overhead paging
[  ] Runner(s)
[  ] Television(s)
[  ] Text paging
[  ] Wireless/cell phone(s)
[  ] Other specify): ___________________________________________________________________________

PD32. Where will decontamination occur? (Check all that apply)

[  ] Ambulance ramp
[  ] Inside the hospital
[  ] Parking lot
[  ] Street/road
[  ] NA
[  ] Other (specify): ___________________________________

PD33. Whose decontamination equipment will be used during the drill? (Check all that apply)

[  ] Fire department owned
[  ] Hospital owned
[  ] Owned by another hospital
[  ] NA
[  ] Other (specify): ___________________________________

PD34. What method will be employed to decontaminate victims? (Check all that apply)

[  ] Emergency medical services (EMS) or fire department vehicles with hoses
[  ] Permanent overhead showers/sprinklers
[  ] Temporary decontamination tent(s)
[  ] NA
[  ] Other (specify):___________________________________

PD35. Which zones do you plan to evaluate during the disaster drill? (Check all that apply)

[  ] Decontamination
[  ] Incident command
[  ] Treatment
[  ] Triage
[  ] Other specify): _____________________________________

PD36. Which specific activities in the disaster drill are most important to evaluate? (Check all that apply)

[  ] Biological illness exposure
[  ] Communications
[  ] Equipment and supplies
[  ] Information flow
[  ] Patient documentation and tracking
[  ] Patient flow
[  ] Personnel
[  ] Personal protective equipment (PPE) and safety
[  ] Radiation exposure
[  ] Rotation of staff
[  ] Security
[  ] Time points
[  ] Zone disruption
[  ] Zone location and boundaries (zone description)
[  ] Zone operations

PD37. Who will function as drill observers (evaluators)? (Check all that apply)

[  ] Administration staff
[  ] Designated hospital clinical staff
[  ] External clinical staff
[  ] Other designated hospital staff
[  ] Other external experts identified
[  ] Other external experts requested
[  ] Other specify): _______________________________________

PD38. Approximately how many observers are you planning to use (minimum one per active zone)
(Enter number): _____________________

PD39. Do you expect to recruit the observers from your hospital? (Check one)

O Yes    O No    O Unclear

PD40. Name of lead observer: ___________________________________________________________________

PD41. Name of lead person planning to conduct the debriefing session: _____________________________________

Title: _________________________________________           Office phone: _________________________________

Hospital: ______________________________________           Cell phone: __________________________________

Street address: _________________________________           Fax: _______________________________________

City and State: _________________________________           Pager: ______________________________________

Best method of contact during the drill. (Check one)

O Cell phone           O Fax           O E-mail           O Office phone           O Pager