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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> > <a href="/prep/" class="crumb_link">Public Health Preparedness Archive</a> > <a href="index.html" class="crumb_link">Disaster Alternate Care Facility Selection Tool</a> > <a href="dacfrep.htm" class="crumb_link">Disaster Alternate Care Facilities: Selection and Operation</a> > Appendix C</span></p>
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<td height="30px"><span class="title"><a name="h1" id="h1"></a>Disaster Alternate Care Facility Selection Tool </span></td>
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<tr>
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<td><div id="centerContent"><p><strong>Public Health Emergency Preparedness</strong></p> <div class="headnote">
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<p>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.</p>
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<!-- <p>Now this resource is supported by the <a href="http://emergency.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC).</p> -->
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<p>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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
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<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
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<h2>Appendix C: Alternate Care Facility Questionnaire</h2>
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<p>As part of a previous task order for the Agency for Healthcare Research and Quality (AHRQ), we developed a site selection matrix for use in the selection of Alternative Care Sites (a.k.a. Alternate Care Facilities, ACF) for use in providing health care during mass casualty events and disasters.<sup><a href="#note1">1</a></sup> We have been asked to revise this tool based on the experience gained during Hurricanes Katrina and Rita and as the result of other planning. We have also been asked to develop protocols for staffing and supplying an ACF, again with input from those who have participated in their use or have done extensive planning for their use.</p>
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<p>You have been identified as an individual who can make a significant contribution to this area of knowledge. Therefore, we kindly ask if you, with input from those you work with (or worked with at your ACF), would be willing to spend a few minutes to assist us with this task. We have developed a questionnaire to facilitate this process (attached). It has two parts; the first asks for information about your actual or planned ACF. The second component asks for your thoughts concerning the usefulness of the different categories of information used in the facility selection tool and for any suggested additions or deletions. Because of the sensitive nature of some of these data, information supplied will be treated confidentially and will not be identified as to any source.</p>
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<p>Thank you in advance for your assistance with this project, which we feel has the potential to help all of us in providing the best possible care for patients during mass casualty events and disasters when we may need to use non-traditional sites of care. The summary results of this effort will be submitted to AHRQ and will subsequently be released to the medical community.</p>
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<p>Please feel free to call or email me if I can be of any help with your participation in this project, or if you feel you are unable to assist us with this project.</p>
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<p>Most sincerely,</p>
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<p>Stephen V. Cantrill, MD<br />
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Denver Health & Hospital Authority<br />
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777 Bannock St.<br />
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Mail Code 8800<br />
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Denver, CO 80204-4507<br />
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Phone: 303-436-7174<br />
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Email: <a href="mailto:stephen.cantrill@dhha.org">stephen.cantrill@dhha.org</a> </p>
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<p>For the Disaster Alternate Care Facility Task Order Group<br />
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Stephen V. Cantrill, MD<br />
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Peter T. Pons, MD<br />
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Carl J. Bonnett, MD<br />
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Sheri L. Eisert, PhD<br />
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Susan L. Moore, Project Manager</p>
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<p>AHRQ Contract No. HHSA290200600020, Task Order No. 4<br />
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Title: Disaster Alternate Care Facilities</p>
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<hr />
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<p class="size2"><a name="note1" id="note1"></a><sup>1</sup> <em>Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency.</em> December 2004. Agency for Healthcare Research and Quality, Rockville, MD. <a href="/research/altsites.htm">https://www.ahrq.gov/research/altsites.htm</a></p>
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<hr />
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<p class="size2"><a href="dacfrep.htm#contents">Return to Contents</a></p>
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<h3>Part One. Information about your past or planned Alternate Care Facility</h3>
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<p><strong>I. Initial Data.</strong></p>
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<p>Please check all that apply to your Alternate Care Facility (ACF), whether actually used or planned:</p>
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<blockquote><strong>These responses are based upon:</strong><br />
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___ A planned ACF (if so, please consider all questions to be in the future tense)<br />
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___ An actual ACF<br />
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<strong> </strong> If an actual ACF, please supply:<br />
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Location/Name: _______________________<br />
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Dates of operation: _____________________<br />
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Total number of patients cared for: _____________________<br />
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Total number of staff utilized: ________________________</blockquote>
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<blockquote><strong>Structure utilized:</strong><br />
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___ Structure of opportunity (a pre-existing building that is, in lieu of its primary purpose, used as a medical facility)</blockquote>
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<blockquote>If so, please specify the structure used (e.g. hotel, retail store, etc): <br />
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_________________________________________________________<br />
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___ Portable (a structure, such as a tent, that can be transported to a location for use as a medical facility)<br />
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___ Mobile (a wheeled structure, such as a trailer, that can be moved or driven to a location for use as a medical facility)
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<p><strong>Function:</strong><br />
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<em> Inpatient Level Care:</em><br />
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<em> </em><u>Health Care Augmentation</u> (augmentation of existing in-patient health care delivery systems, either on site at the traditional health care delivery location or at a more distant site)<br />
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___ Adult <br />
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___ Pediatric<br />
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___ Special Populations (e.g. prisoners)<br />
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Please specify: ____________________________________________<br />
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____________________________________________________________<br />
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___ Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)<br />
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Please specify:_______________________<br />
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_________________________________________________</p>
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</blockquote>
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<blockquote> <u>Health Care Replacement</u> (replacement of existing in-patient health care systems that have been directly affected by the incident)<br />
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___ Adult <br />
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___ Pediatric<br />
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___ Special Populations (e.g. prisoners)<br />
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Please specify: _____________________________________________<br />
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_____________________________________________________________<br />
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___ Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)<br />
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Please specify:_____________________________________________<br />
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_____________________________________________________________</blockquote>
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<blockquote><p><em>Ambulatory/Primary Care:</em><br />
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<u>Health Care Augmentation</u> (augmentation of existing out-patient health care delivery systems, either on site at the traditional health care delivery location or at a more distant site)<br />
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___ Adult <br />
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___ Pediatric<br />
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___ Public Health Support (vaccinations, prophylaxis, triage)</p>
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<p> <u>Health Care Replacement</u> (replacement of existing in-patient health care systems that have been directly affected by the incident)<br />
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____ Adult <br />
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___ Pediatric<br />
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___ Special Populations (e.g. prisoners)<br />
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Please specify: _____________________________________________<br />
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_____________________________________________________________<br />
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___ Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)<br />
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Please specify: _____________________________________________<br />
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_____________________________________________________________<br />
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___ Shelter Support (routine ambulatory medical support necessary for shelter operations for a displaced population) </p></blockquote>
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<blockquote><p><strong>Governance:</strong> (the organization responsible for the oversight, command, and operation of the ACF)<br />
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___ Institutional/Health care system (Hospital or hospital system based)<br />
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___ Nonprofit/Volunteer/Faith-Based (e.g. Red Cross, Salvation Army)<br />
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___ Local (Local government/Municipal/County)<br />
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___ Office of Emergency Management<br />
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___ Public Health<br />
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___ Other: Please specify: _________________________________________<br />
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___ State<br />
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___ Federal<br />
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___ DHHS<br />
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___ PHS (FMS)<br />
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___ NDMS (DMAT, NMRT)<br />
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___ Other: Please specify: _______________________<br />
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___ Department of Defense</p>
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</blockquote>
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<p><strong>II. ACF Command Structure</strong></p>
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<p><strong>A. General</strong></p>
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<blockquote><p>1. Did you set up an incident command system at your ACF?<br />
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___ Yes ___ No<br />
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1a. If so, what was it modeled on (e.g. HICS)? ___________________________</p>
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<p>2. Was an Incident Action Plan (IAP) prepared?<br />
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___ Yes ___ No<br />
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2a. If yes, was it done: <br />
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___ Once ___ Daily ___ Other frequency: _____________________________<br />
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2b. Was the IAP a: <br />
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___ Previously prepared form ___ A form we created</p>
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<p>3. Were there any problems with the command structure? <br />
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___ Yes ___ No<br />
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3a. If yes, please elaborate: _________________________________________<br />
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________________________________________________________________</p>
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<p>4. How was the transfer of command facilitated at change of shift:<br />
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___ Verbal report ___ Written report<br />
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___ Both ___ Other (Please specify): ___________________________</p>
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<p>5. How did you decide to open your ACF: _________________________________________<br />
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_______________________________________________________________________<br />
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_______________________________________________________________________</p>
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<p>6. Who made the decision (by job title, not name): __________________________________<br />
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_______________________________________________________________________</p>
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<p>7. How did you decide to close it:_________________________________________________<br />
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________________________________________________________________________<br />
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________________________________________________________________________</p>
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<p>8. What, if any, were the predetermined requirements to be met before closing it: ____________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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<p>9. Did you have a concept of operations (or operational plan) which you adhered to? <br />
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___ Yes ___ No</p>
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<p>10. Did your command staff have National Incident Management System and/or Hospital Incident Command System Training? <br />
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___ Yes ___ No<br />
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10a. If yes, what percentage of the staff were trained:____________<u>%</u></p>
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<p>11. Did you have any issues related to the Emergency Medical Treatment & Active Labor Act (EMTALA) during the operation of your ACF?<br />
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___ Yes ___ No<br />
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11a. If so, what were the issues and how did you handle them: ________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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<p>12. Were there any issues related to public information management?<br />
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___ Yes ___ No<br />
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12a. If so, please specify: _____________________________________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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<p>13. How did you coordinate the dispatch of EMS resources to the ACF with the everyday dispatch operations of the local community: ________________________________________________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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<p>14. Did you have rules of behavior for the patients (e.g. curfew, no weapons, lights out time)?<br />
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__ Yes ___ No<br />
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14a. If yes, please list or include with the returned questionnaire: _______________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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<p>15. Are there any other issues with regards to the command of an ACF which you would like to share?<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________<br />
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_________________________________________________________________________</p>
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</blockquote>
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<p><strong>B. Security</strong></p>
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<blockquote><p>1. Did you have uniformed security personnel at your ACF?<br />
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___ Yes ___ No</p>
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<p>2. If so, were any of them armed?<br />
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___ Yes ___ No</p>
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<p>3. Did you have any issues with violence at your ACF?<br />
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___ Yes ___ No</p>
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<p>4. Are there any other issues related to the security of an ACF that you believe are important and wish to share? ____________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________</p>
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</blockquote>
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<p><strong>III. ACF Planning Component</strong></p>
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<p><strong>A. General</strong></p>
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<blockquote><p>1. Did you have a plan for an ACF before you were called upon to stand one up? <br />
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___ Yes ___ No</p>
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<p>2. Did you select the site for your ACF after the need for it arose or had the site been determined in advance of the event?<br />
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___ When need arose ___ Determined in advance </p>
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<p>3. Were you familiar with the Rocky Mountain Regional Care Model for Bioterrorist Events Alternative Care Site Selection Tool prior to setting up your ACF (go to <a href="dacfrepappa.htm">Appendix A</a>)? <br />
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___ Yes ___ No<br />
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3a. If yes, did you use this tool to help select the site of your ACF? <br />
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___ Yes ___ No<br />
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3b. If not, do you think it would have been helpful?<br />
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___ Yes ___ No</p>
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<p>4. What consideration, if any, was given to locating the ACF in proximity to the transportation network and/or evacuation routes?<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________</p>
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<p>5. Any other issues with regards to site selection which you would like to share: ______________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________<br />
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___________________________________________________________________________</p>
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<p>6. Did you have plans for the following services?<br />
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___ Social services<br />
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___ Cleaning services<br />
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___ Recreational services<br />
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___ Warehousing services<br />
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___ Contracting/purchasing services<br />
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___ Other services:<br />
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Please specify: ____________________________________________________________</p>
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<p>7. Are there any other issues with regards to additional services which you would like to share: <br />
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__________________________________________________________________________<br />
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__________________________________________________________________________<br />
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__________________________________________________________________________</p>
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</blockquote>
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<p><strong>B. Bed/Case Mix</strong></p>
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<blockquote>1. What percentage of each of the following did you <em>expect/plan for</em> at your ACF?<br />
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___ Acute care cases: _____<u>%</u> Chronic care cases: _____<u>%</u><br />
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___ Pediatric patients: _____<u>%</u> Adult patients: _____<u> %</u><br />
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___ No specific expectations<p></p>
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<p>2. What percentage of each of the following did you <em>actually</em> <em>receive</em> at your ACF?<br />
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___ Acute care cases: _____<u>%</u> Chronic care cases: _____<u>%</u><br />
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___ Pediatric patients:_____<u> %</u> Adult patients: _____<u>%</u><br />
|
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___ No specific expectations</p>
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|
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<p>3. Have you changed your bed/case mix plans for future ACFs as a result?<br />
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___ Yes ___ No<br />
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3a. If so, please specify: _________________________________________</p></blockquote>
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<p><strong>C. Pediatrics</strong></p>
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<blockquote><p>1. Was the care of children an integral part of your initial plan?<br />
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___ Yes ___ No</p>
|
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|
|
<p>2. Was there a specific location within your ACF set aside for the care of children?<br />
|
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___ Yes ___ No</p>
|
|
|
|
<p>3. Which of the following types of individuals were involved in the <u>planning</u> for the care of children (please check all that apply)?<br />
|
|
___ Emergency nurses?<br />
|
|
___ Emergency physicians?<br />
|
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___ Midlevel practitioners (e.g. nurse practitioners, physician assistants)?<br />
|
|
___ Pediatric emergency physicians?<br />
|
|
___ Pediatric nurses?<br />
|
|
___ Other?<br />
|
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Please specify: _________________________________________________________</p>
|
|
|
|
<p>4. Were any of the following consulted to help plan for pediatric patients (please check all that apply)?<br />
|
|
___ Pediatric tertiary care center?<br />
|
|
___ Pediatrics department at your local hospital?<br />
|
|
___ Other? <br />
|
|
Please specify: _______________________________________________________</p>
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</blockquote>
|
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|
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<p><strong>IV. ACF Logistics</strong></p>
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<p><strong>A. General</strong></p>
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|
|
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<blockquote>
|
|
<p>1.Who provided the equipment to stand up your ACF? _________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
|
|
<p>2. Who provided you with re-supply? ______________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>3. Did you tap into any federally administered medical supply caches?<br />
|
|
____ Yes ____ No<br />
|
|
3a. If so, please specify which one(s): ___________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>4. Did you have any partnerships with private industry to help provide service or supplies at your ACF (e.g. commercial pharmacies)?<br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>5. How did you feed the health care workers and patients at your ACF? ____________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>6. Did you also provide food for the families of patients?<br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>7. Was the dining area separate from the treatment area? <br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>8. Did you have medications for children? <br />
|
|
____ Yes ____ No<br />
|
|
8a. If so, did you have appropriate type and quantity of medications for pediatric patients?<br />
|
|
____ Yes ____No<br />
|
|
8b. Who supplied them? _____________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>9. Did you have other medical supplies for children? <br />
|
|
____ Yes ____ No<br />
|
|
9a. If yes, did you have adequate quantity?<br />
|
|
____ Yes ____ No<br />
|
|
9b. Who supplied them? ______________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>10. What supplies, equipment, and drugs were most important to the operation of your ACF? <br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>11. What supplies/equipment/drugs that you needed could not be obtained? _______________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>12. Are there any other issues with regards to general logistics that you would like to share: <br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
</blockquote>
|
|
|
|
<p><strong>B. Staffing & Credentialing</strong></p>
|
|
|
|
<blockquote><p>1. Did you have set shifts which were worked by health care providers?<br />
|
|
____ Yes ____ No<br />
|
|
1a. If yes, were they:<br />
|
|
____ 8 hour ____ 12 hour ____ Other: _____________________________ </p>
|
|
|
|
<p>2. Did you have different staffing patterns for day vs. night?<br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>3. How many physicians did you have working at one time? _____________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>4. How many midlevel practitioners did you have working at one time?____________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>5. How many nurses did you have working at one time?________________________________<br />
|
|
_________________________________________________________________________</p>
|
|
|
|
<p>6. How many emergency medical technicians did you have working at one time?_____________<br />
|
|
__________________________________________________________________________</p>
|
|
|
|
<p>7. How many pharmacists did you have working at one time? ____________________________<br />
|
|
__________________________________________________________________________</p>
|
|
|
|
<p>8. Did you have dedicated clerks and/or administrative support?<br />
|
|
____ Yes ____ No<br />
|
|
8a. If so, how many did you utilize? ________________________________________________<br />
|
|
__________________________________________________________________________</p>
|
|
|
|
<p>9. Did you have health care providers from different health care facilities/systems working in your ACF?<br />
|
|
____ Yes ____ No<br />
|
|
9a. If so, were there any command and control issues and how did you resolve them? ________<br />
|
|
___________________________________________________________________________<br />
|
|
___________________________________________________________________________<br />
|
|
___________________________________________________________________________</p>
|
|
|
|
<p>10. Were there any out-of-state licensing issues?<br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>11. Did you have a need for interpreter services? <br />
|
|
____ Yes ____ No<br />
|
|
11a. If so, how did you meet that need?
|
|
<br />
|
|
____Trained interpreters<br />
|
|
____Bilingual/multilingual care providers<br />
|
|
____Family members<br />
|
|
____Other<br />
|
|
Please specify:________________________________________________________________</p>
|
|
|
|
<p>12. What types of volunteers were utilized?<br />
|
|
____ None ____ Medical ____ Non-medical<br />
|
|
12a. Did you have a volunteer coordinator?<br />
|
|
____ Yes ____ No</p>
|
|
|
|
<p>13. What lessons did you learn with regards to integrating non-health care provider volunteers into the operation of the ACF? ________________________________________________________________________________<br />
|
|
________________________________________________________________________________<br />
|
|
________________________________________________________________________________</p>
|
|
|
|
<p>14. How did you verify the credentials of health care providers who worked in your ACF?____________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________</p>
|
|
|
|
<p>15. Did you create identification cards for the workers?<br />
|
|
____ Yes ____ No<br />
|
|
15a. If so, what did you use (e.g. commercially available product)?___________________________<br />
|
|
______________________________________________________________________________</p>
|
|
|
|
<p>16. Is there anything you would do differently for worker identification in the future?________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________</p>
|
|
|
|
<p>17. Did you have anyone impersonate a health care provider and try to gain access to your ACF?<br />
|
|
____ Yes ____No</p>
|
|
|
|
<p>18. What steps were taken at the State level to facilitate the use of out-of-state medical professionals?<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________</p>
|
|
|
|
<p>19. Did your staff have any specialized pre-event training? <br />
|
|
____Yes ____No<br />
|
|
If yes, please specify: _____________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________</p>
|
|
|
|
<p>20. Are there any other issues with regards to staffing or credentialing which you would like to share (including what other staff you found helpful to have)? ____________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________<br />
|
|
______________________________________________________________________________</p>
|
|
</blockquote>
|
|
|
|
<p class="size2"><a href="dacfrep.htm#contents">Return to Contents</a><br />
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<a href="dacfrepappc2.htm">Proceed to Next Section</a></p>
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