9k. 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): ___________________________

10a. Were there appropriate quantities of medical supplies?   Y / N / U

Comments:

Were these medical supplies available?

If the medical supplies were not available, circle "N" in column "A" and go to the next row.

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:

2a. Were the zone boundaries clearly defined?   Y / N / U

Comments:

2b. What type of unit is this zone during regular hospital functioning? (Check all that apply.)

a. ___ Emergency Department (ED)    b. ___ Intensive Care (ICU)

c. ___ Medical Inpatient                       d. ___ Medical Outpatient

e. ___ Surgical Inpatient                       f. ___ Surgical Outpatient

g. ___ Other (specify): _______________________________________________________

3a. Did someone assume command of this zone?   Y / N / U

Comments:

3b. Was staffing of the treatment zone adequate?   Y / N / U

Comments:

3c. How many minutes after the drill activities in this zone commenced did someone 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.

3d. Were the following drill participants identifiable?

a. Drill evaluators  Y / N / U / NA   b. Drill organizers  Y / N / U / NA

c. Media  Y / N / U / NA                 d. Medical personnel  Y / N / U / NA

e. Mock victims  Y / N / U / NA       f. Observers  Y / N / U / NA

g. Security  Y / N / U / NA

4a. Did the treatment area function efficiently?    Y / N / U

Comments:

4c. 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): ___________________________________

4d. 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): ____________________________________

4e. Was the space allocated for the zone adequate?   Y / N / U

If space allocated was not adequate, specify in comment box at end of this module.

4f. 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.

4g. How were victims managed who were not previously triaged? (Check one.)

___ Sent back to triage zone   ___ Sent to another area (specify): ________________________

___ Triaged in this zone           ___ Treated without being triaged

5a. Were all incoming victims registered and given a unique identification or medical record number?   Y / N / U

Comments:

5b. When were all 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

5c. What was the method of documenting the victim record in this zone? (Check all that apply.)

a. ___ Computer entry         b. ___ Data card(s) attached to victims

c. ___ Dictation system       d. ___ Personal data assistant (PDA)

e. ___ Scanner                   f. ___ Separate victim paper chart

g. ___ No documentation    h. ___ Expedited registration

i. ___ Other (specify): ________________________________

6a. Were communications effective?   Y / N / U

Comments:

7a. Was necessary information received?   Y / N / U

Comments:

7c. How was this zone kept aware of the ongoing general situation within the hospital? (Check all that apply.)

a. ___ Call from incident command                   b. ___ Fax from incident command

c. ___ Other contact from incident command    d. ___ Runner(s) from incident command

e. ___ Contact from other internal sources (specify): _________________________________________

8a. Were entrances and exits strictly controlled in this area?   Y / N / U

Comments:

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): _________________________________

9a. Was an appropriate supply of PPE available?   Y / N / U

Comments:

9b. Was the PPE applied correctly?   Y / N / U

Comments:

If safety materials were not available, circle "N" in column "A" and go to the next row.

9k. 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): ____________________________

10a. Were there appropriate quantities of medical supplies?   Y / N / U

Comments: