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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="." class="crumb_link">Tool for Evaluating Core Elements of Hospital Disaster Drills</a> > Modules and Addenda</span></p>
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<td height="30px"><span class="title"><a name="h1" id="h1"></a>Tool for Evaluating Core Elements of Hospital Disaster Drills</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>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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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>Modules and Addenda</h2>
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<hr />
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<p>Select to download print version of the modules and addenda (<a href="/prep/drillelements/drillelementsmod.pdf">PDF File</a>, 388 KB; <a href="/pdfhelp.htm">PDF Help</a>).</p>
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<hr />
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<a name="contents" id="contents"></a>
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<h3>Contents</h3>
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<p><a href="#pre">Pre-Drill Module</a> <br />
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<a href="#incid">Incident Command Center Zone Module</a> <br />
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<a href="#decon">Decontamination Zone Module</a> <br />
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<a href="drillelementsmod2.htm#triage">Triage Zone Module</a> <br />
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<a href="drillelementsmod2.htm#treat">Treatment Zone Module</a> <br />
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<a href="drillelementsmod3.htm#biol">Biological Incident Addendum</a> <br />
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<a href="drillelementsmod3.htm#rad">Radiological Incident Addendum</a> <br />
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<a href="drillelementsmod3.htm#group">Group Debriefing Module</a></p>
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<p>Select to download print version (<a href="/prep/drillelements/drillelements.pdf">PDF File</a>, KB; <a href="/pdfhelp.htm">PDF Help</a>).</p>
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<a name="pre" id="pre"></a>
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<h3>Pre-drill Module</h3>
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<p><strong>Note:</strong> Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable</p>
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<p><strong>Background Information</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td><p>1.a Name of person completing module: ____________________________________________</p>
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<p>Title: ________________________________________________________________________</p>
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<p>Office phone: _________________________________________________________________</p>
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<p>Hospital: _____________________________________________________________________</p>
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<p>Cell phone: ___________________________________________________________________</p>
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<p>Room number: ________________________________________________________________</p>
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<p>E-mail: ______________________________________________________________________</p>
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<p>Street address: ________________________________________________________________</p>
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<p>Fax: _________________________________________________________________________</p>
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<p>City and state: _________________________________________________________________</p>
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<p>Pager: _______________________________________________________________________</p>
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<p>Best method of contact during the drill. <strong>(Circle one.)</strong><br />
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Cell phone E-mail Fax Office phone Pager</p>
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</td></tr></table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>1.b. What will the disaster scenario include? <strong>(Check all that apply.)</strong></p>
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<p> ___ Biological agent ___ Chemical agent</p>
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<p>___ Fire ___ Incendiary device/explosive</p>
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<p>___ Natural disaster (e.g., earthquake) ___ Radiological agent</p>
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<p>___ Structural collapse ___ Transportation accident</p>
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<p>___ Internal hospital system failure (specify): _____________________________________</p>
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<p>___ Other (specify): _________________________________________________________</p>
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</td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>
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<p>1.c Will the drill include decontamination? Y / N / U</p>
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</td>
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</tr>
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</table>
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<p><strong>2. Level and Scope of the Hospital Drill Activity</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td><p>2.a What type of disaster drill is your hospital performing? <strong>(Check one.)</strong></p>
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<p>___ Operationalized drill</p>
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<p>___ Tabletop Exercise</p>
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<p>___ Computer Simulation</p>
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<p>___ Other (specify): _________________________________________________________ </p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>2.b. What is your main overall goal for the disaster drill? <strong>(Please limit to one sentence and include previous after-action items as appropriate.)</strong></p>
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<p> </p>
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<p> </p>
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<p> </p>
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<p> </p>
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<p> </p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>2.c What are the specific objectives for the disaster drill? <strong>(Please limit to one sentence each.)</strong></p>
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<ol type="a">
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<li> </li>
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<li> </li>
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<li> </li>
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<li> </li>
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</ol>
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</td>
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</tr>
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</table>
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<p><strong>3. Drill Activity</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td><p>3.a How will the notification to initiate the drill occur? <strong>(Check all that apply.)</strong></p>
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<p>___ By another hospital ___ By first victim arrival</p>
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<p>___ By health department ___ By government agency (e.g., federal or state emergency agency)</p>
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<p>___ EMS dispatch center</p>
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<p>___ Other (specify): ___________________________________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3.b Which hospital personnel (not including victims or observers) from the following staff groups will actively participate in the drill activities? <strong>(Check all that apply.)</strong></p> <p>___ Administration</p>
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<p>___ Engineering and physical plant</p>
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<p>___ Laboratory</p>
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<p>___ Occupational health</p>
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<p>___ Radiation safety</p>
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<p>___ Social work</p>
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<p>___ Pediatrics department</p>
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<p>___ Surgery department</p> <p> ___ Central supply</p>
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<p>___ Infection control</p>
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<p>___ Medical staff</p>
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<p> ___ Pharmacy</p>
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<p>___ Safety</p>
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<p>___ Emergency department</p>
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<p>___ Psychiatry department</p>
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<p>___ Hospital-wide</p> <p>___ EMS/patient transport service </p>
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<p> ___ Intensive care unit</p>
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<p> ___ Nursing</p>
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<p>___ Public affairs</p>
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<p>___ Security</p>
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<p> ___ Medicine department</p>
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<p> ___ Radiology department</p> <p>___ Other (specify): _________________________________________________________</p>
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<p>___ Other (specify): _________________________________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3.c What levels of activity will be included in the drill? <strong>(Check all that apply.)</strong></p>
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<p>___ Materials and supplies received</p>
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<p>___ Triage of victims</p>
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<p>___ Simulated clinical procedures performed</p>
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<p>___ Victim decontamination</p>
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<p>___ Victim transport in the emergency department only</p>
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<p>___ Victim transport throughout hospital</p>
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<p>___ Other (specify): _________________________________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3.d What other organizations/agencies will be involved in the drill? <strong>(Check all that apply.)</strong></p>
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<p>___ Ambulance system ___ Hospital/health systems(s) (specify): ____________________</p>
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<p>___ Fire ___ City/local agency(ies) (specify): ________________________</p>
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<p>___ Media ___ State agency(ies) (specify): ___________________________</p>
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<p>___ Police ___ Federal agency(ies) (specify): _________________________</p>
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<p>___ Military (specify): _______________________________________________________</p>
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<p>___ Other (specify): ________________________________________________________</p></td>
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</tr>
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</table>
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<p><strong>4. Incident Command</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td><p>4.a Will there be an incident command center? <strong>(Check one.)</strong></p>
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<p>___ Yes If yes, where is its location? ___________________________________________</p>
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<p>___ No</p></td>
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</tr>
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</table>
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<p><strong>5. Communications</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td><p>5.a What methods will personnel use to communicate during the drill? <strong>(Check all that apply.)</strong></p> <p>___ 2-way radio/phone(s)</p>
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<p>___ Fax machine(s)</p>
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<p>___ Megaphone(s)</p>
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<p>___ PDA(s) </p>
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<p>___ Text paging</p> <p>___ E-mail/Internet/network</p>
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<p>___ Intercom</p>
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<p>___ Numeric paging</p>
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<p>___ Runner(s)</p>
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<p>___ Wireless/cell phone(s)</p> <p>___ Emergency radio</p>
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<p>___ Landline phone(s)</p>
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<p>___ Overhead paging</p>
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<p>___ Satellite phone(s)</p>
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<p>___ Ham radio</p>
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<p>___ Other (specify): _________________________________________________________</p>
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</td>
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</tr>
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</table>
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<p><strong>6. Evaluation</strong> </p>
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<table border="1" cellspacing="0" cellpadding="8" width="95%">
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<tr>
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<td colspan="2"><p>6.a Which aspects do you plan to evaluate during the disaster drill? <strong>(Check all that apply.)</strong></p></td>
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</tr>
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<tr valign="top">
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<td><p>___ Decontamination</p>
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<p>___ Treatment</p>
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<p>___ Biological illness exposure</p>
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<p>___ Communication and information flow</p>
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<p>___ Facility engineering</p>
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<p>___ Patient flow</p>
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<p>___ Radiation exposure</p>
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<p>___ Security</p>
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<p>___ Surge capacity</p>
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<p>___ Zone disruption</p></td>
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<td><p>___ Incident command</p>
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<p>___ Triage</p>
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<p>___ Chemical exposure</p>
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<p>___ Equipment and supplies</p>
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<p>___ Patient documentation and tracking</p>
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<p>___ Personal protective equipment (PPE) use</p>
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<p>___ Rotation of staff</p>
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<p>___ Staffing</p>
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<p>___ Time points</p>
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<p>___ Zone operations</p>
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</td>
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</tr>
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<tr>
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<td colspan="2"><p>___ Other (specify): _________________________________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>6.b Name of lead person, if different than 1.a, planning to conduct the debriefing session:</p>
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<p>__________________________________________________________________________</p>
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<p>Title: ______________________________________________________________________</p>
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<p>Office phone: _______________________________________________________________</p>
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<p>Hospital: __________________________________________________________________</p>
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<p>Cell phone: ________________________________________________________________</p>
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<p>Room number: _____________________________________________________________</p>
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<p>Street address: _____________________________________________________________</p>
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<p>Fax: ______________________________________________________________________</p>
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<p>City and state: ______________________________________________________________</p>
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<p>Pager: ____________________________________________________________________</p>
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<p>Best method of contact during the drill. <strong>(Check one.)</strong></p>
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<p>___ Cell phone ___ E-mail ___ Fax ___ Office phone ___ Pager</p></td>
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</tr>
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</table>
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<p class="size2"><a href="index.html#contents">Return to Contents</a></p>
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<a name="incid" id="incid"></a>
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<h3>Incident Command Center Zone Module</h3>
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<p><strong>Note</strong>: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable</p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>Observer: _________________________________________ Date: ____/____/_______</p>
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<p>Observer title: ____________________________________________________________</p>
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<p>Hospital: ________________________________________________________________</p>
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<p>Period of time of evaluation: ______ AM/PM (<strong>Circle one</strong>.) to _____ AM/PM (<strong>Circle one.</strong>)</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>1. Time Points</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>1a. <strong>Did the drill start on time?</strong> Y / N / U</p>
|
|
<p>Comments:</p> <p>1b. Time the drill began: <strong>(Circle one.)</strong> ______ AM / PM / U</p> <p>1c. Time the hospital disaster plan was initiated in this zone: ______ AM / PM / U / Not initiated<br />
|
|
<strong>(Circle one.)</strong></p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>2. Personnel</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>2a. <strong>Was an incident command system established?</strong> Y / N / U</p> <p>Comments:</p><br /><br /><br /><br /></td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>2b. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (<strong>Check one</strong>.)</p>
|
|
|
|
<p>___ <10 min ___ 10 - 29 min ___ 30 - 59 min</p>
|
|
|
|
<p>___ 1 - 2 hrs ___>2 hrs ___NA</p>
|
|
|
|
<p>___ No one took charge. </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>2c. Were the following drill participants identifiable?</p>
|
|
|
|
<p>a. Incident Commander Y / N / U / NA b. Incident Command Personnel Y / N / U / NA</p>
|
|
|
|
<p>c. Drill Evaluators Y / N / U / NA d. Drill Organizers Y / N / U / NA</p>
|
|
|
|
<p>e. Security Y / N / U / NA </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>Was someone fulfilling the functions of the following roles (within the incident command center or elsewhere) or reporting to the incident command center?</p>
|
|
<p><strong>If no one fulfilled a specified function, circle "N" in column "A" and go to the next row.</strong></p></td>
|
|
</tr><tr>
|
|
<td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr align="left"><th scope="col">Functional Role</th>
|
|
<th scope="col">A. Function Filled</th>
|
|
<th scope="col">B. Comments</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row" width="50%">2d. Incident Commander</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">2e. Logistics Chief (oversees facilities, communications, patient transportation, and supplies)</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">2f. Planning Chief (oversees staffing)</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">2g. Operations Chief (oversees patient care, ancillary services, and staff support)</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">2h. Other (specify): ____________________________ </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
</table></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>3. Zone Operations</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3a. <strong>Did the incident command center function efficiently?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>3b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>3c. If not followed, what were the reason(s)? (<strong>Check all that apply.</strong>)
|
|
|
|
<p>a. ___ Not available b. ___ Too complex</p>
|
|
<p>c. ___ Not relevant to drill d. ___ Participants unfamiliar with plan</p>
|
|
<p>e. ___ Too hard to access f. ___ Other (specify):_________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3d. If the hospital disaster plan was available, what was its format? (<strong>Check all that apply</strong>.)</p>
|
|
|
|
<p>a. ___ Complete manual b. ___ Flow diagram c. ___ Job action sheets</p>
|
|
<p>d. ___ No disaster plan e. ___ Other (specify): __________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>4. Communications</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>4a. Were communications effective?</strong> Y / N / U</p>
|
|
<p>Comments:</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>Were the following communications devices used in the drill for internal or external communications? (<strong>Check all that apply.</strong>)</td>
|
|
</tr>
|
|
<tr>
|
|
<td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr>
|
|
<th scope="col">Communications Device</th>
|
|
<th scope="col">A. Internal</th>
|
|
<th scope="col">B. External</th>
|
|
<th scope="col">C. Comments (Note strengths and weaknesses.)</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4b. 2-way radio/phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4c. Landline phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4d. Wireless/cell phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4e. Personal data assistant(s) (PDA)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4f. Numeric paging </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4g. Overhead paging</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4h. Text paging</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4i. E-mail/Internet access/network</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4j. Fax machine(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4k. Intercom</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4l. Megaphone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4m. Runner(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4n. Satellite phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4o. Ham Radio</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">4p. Emergency radio</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr></table></td>
|
|
</tr>
|
|
</table></div></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4q. How was incoming information to the zone recorded? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Computer (or other electronic device) b. ___ Notepaper</p>
|
|
|
|
<p>c. ___ Posted paper d. ___ White board/chalk board</p>
|
|
|
|
<p>e. ___ Not recorded f. ___ Other (specify): _________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>5. Information Flow</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>5a. Was necessary information received?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>5b. Did the incident command center receive timely updates regarding the total number of expected victims? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>5c. Were problems created by delays in receiving information? Y / N / U</p>
|
|
|
|
<p><strong>If problems were created by delays in information, specify in comment box at end of this module.</strong></p> </td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>6. Security</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>6a. Were entrances and exits strictly controlled in this area?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p>
|
|
<p> </p>
|
|
<p> </p>
|
|
<p> </p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>7. Rotation of Staff</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p> <strong>7a. Were incoming staff updated?</strong> Y / N / U</p> <p><strong>Comments: (If comment refers to a specific item, give the item number):</strong></p><br /><br /><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p class="size2"><a href="index.html#contents">Return to Contents</a></p>
|
|
|
|
<a name="decon" id="decon"></a>
|
|
<h3>Decontamination Zone Module</h3>
|
|
<p><strong>Note</strong>: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable</p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>Observer: _________________________________________ Date: ____/____/_______</p>
|
|
|
|
<p>Observer title: ____________________________________________________________</p>
|
|
|
|
<p>Hospital: ________________________________________________________________</p>
|
|
|
|
<p>Period of time of evaluation: ______ AM/PM (<strong>Circle one</strong>.) to _____ AM/PM (<strong>Circle one.</strong>)</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>1. Time Points</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>1a. <strong>Did the drill start on time?</strong> Y / N / U</p>
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>1b. Time the drill began: <strong>(Circle one.)</strong> ______ AM / PM / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>1c. Time this zone was ready to accept victims: <strong>(Circle one.)</strong> ______ AM / PM / U </td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>Zone Description</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>2a. Were the zone boundaries clearly defined?</strong> Y / N / U</p>
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>2b. How was the boundary for this zone defined? <strong>(Check all that apply.)</strong></p>
|
|
|
|
<p>a. ___ Barricade(s) b. ___ Sign(s) c. ___ Tape</p>
|
|
<p>d. ___ Wall(s) e. ___ No boundary f. ___ Other (specify): _________________</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>3. Personnel</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3a. <strong>Did someone assume command of this zone?</strong> Y / N / U</p>
|
|
<p>Comments:</p><br /><br /><br /></td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3b. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (<strong>Check one</strong>.)</p>
|
|
|
|
<p>___ <10 min ___ 10 - 29 min ___ 30 - 59 min</p>
|
|
|
|
<p>___ 1 - 2 hrs ___>2 hrs ___NA</p>
|
|
|
|
<p>___ No one took charge. </p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>4. Zone Operations</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4a. <strong>Did the decontamination area operations function efficiently?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>4b. Was the decontamination zone set up prior to the arrival of first victim? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4c. Were there problems with decontamination of non-ambulatory victims?</p>
|
|
<p>___ Yes ___ No ___ No non-ambulatory victims ___ Unclear</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4d. Were victims' clothing and personal belongings removed during decontamination? Y / N / U</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4e. Were victims' clothing and personal belongings marked as hazardous and secured?</p>
|
|
<blockquote>Y / N / U</blockquote></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4f. Mechanism of decontamination? (<strong>Check all that apply and estimate the number</strong>.)</p>
|
|
|
|
<p>a. ___ EMS or fire department vehicles with hoses (number: _______)</p>
|
|
<p>b. ___ Permanent overhead showers/sprinklers (number: _______)</p>
|
|
|
|
<p>c. ___ Temporary decontamination tent(s) (number: _______)</p>
|
|
|
|
<p>d. ___ Indoor decontamination facilities (number: _______)</p>
|
|
|
|
<p>e. ___ Other (specify): ____________________________________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4g. Was medical oversight of victims maintained through the decontamination process?</p>
|
|
<blockquote>Y / N / U</blockquote></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4h. Did a bottleneck develop in this zone? Y / N / U</p>
|
|
<p><strong>If a bottleneck did develop, describe in the comment box at the end of this module.</strong></p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>5. Victim Documentation and Tracking:</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>5a. Were all incoming victims registered and given a unique identification or medical record number?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>5b. When were incoming victims registered and given a unique identification or medical record number? (<strong>Check one.</strong>)</p>
|
|
|
|
<p>___ Before entering this zone ___ On entering this zone</p>
|
|
|
|
<p>___ Not while in this zone ___ Unclear</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
|
|
<p><strong>6. Communications</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>6a. Were communications effective?</strong> Y / N / U</p>
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
<tr>
|
|
<td>Were the following communications devices used in the drill for communication? (<strong>Check all that apply.</strong>)</td>
|
|
</tr> <tr>
|
|
<td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr>
|
|
<th scope="col">Communications Device</th>
|
|
<th scope="col">A. Used</th>
|
|
<th scope="col">B. Comments (Note strengths and weaknesses.)</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6b. 2-way radio/phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
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</tr>
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<tr>
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<td scope="row">6c. Intercom </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6d. Megaphone(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6e. Runner(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
|
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<td scope="row">6f. Cell phones </td>
|
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<td> </td>
|
|
<td> </td>
|
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</tr>
|
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<tr>
|
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<td scope="row">6g. Text paging</td>
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<td> </td>
|
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<td> </td>
|
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</tr>
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<tr>
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<td scope="row">6h. Fax machine(s)</td>
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<td> </td>
|
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<td> </td>
|
|
</tr>
|
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<tr>
|
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<td scope="row">6i. Personal data assistant(s) (PDA)</td>
|
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<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
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<td scope="row">6j. E-mail/Internet/network </td>
|
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<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
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<td scope="row">6k. Numeric paging </td>
|
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<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6l. Emergency radio </td>
|
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<td> </td>
|
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<td> </td>
|
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</tr>
|
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<tr>
|
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<td scope="row">6m. Ham radio </td>
|
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<td> </td>
|
|
<td> </td>
|
|
</tr>
|
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<tr>
|
|
<td scope="row">6n. Landline phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6o. Satellite phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6p. Overhead paging</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row"><p>6q. Other (specify): _______________ </p></td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
</table></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>7. Information Flow</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td ><p><strong>7a. Was necessary information received?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>7b. Were problems created by delays in receiving information? Y / N / U</p>
|
|
|
|
<p><strong>If problems were created by delays in information, specify in comment box at end of this module.</strong></p> </td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>7c. When was your zone made aware of the potential involvement of a chemical or radiological agent? (<strong>Check one.</strong>)</p>
|
|
|
|
<p>___ Before the first victim arrived ___ After first victim arrived</p>
|
|
<p>___ All victims completed decontamination ___ Never made aware</p>
|
|
<p>___ Unsure</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>8. Security</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>8a. Were entrances and exits strictly controlled in this area?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>8b. Did any of the following security issues arise in this zone? (<strong>Check all that apply</strong>)</p>
|
|
|
|
<p>a. ___ Crowd control b. ___ Media control</p>
|
|
|
|
<p>c. ___ Unruly victims d. ___ Other (specify): _____________________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>8c. Were security personnel present in this zone? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>9. Personal Protective Equipment (PPE) and Safety:</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td ><p><strong>9a. Was an appropriate supply of PPE available?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9b. Was the PPE applied correctly? Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9c. Was staffing of the decontamination zone adequate? Y / N / U</p>
|
|
|
|
<p>Comments:</p><br />
|
|
<p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>If needed, were these items for standard precautions available for the healthcare workers? </p>
|
|
<p><strong>If safety materials were not available, circle "N" in column "A" and go to the next row.</strong></p> </td>
|
|
</tr><tr>
|
|
<td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
|
|
<tr align="left">
|
|
<th scope="col">Safety material</th>
|
|
<th scope="col">A. Available</th>
|
|
<th scope="col">B. Used by staff?</th>
|
|
<th scope="col">C. Adequate supply?</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9d. Protective suit</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9e. Hoods </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9f. Boots </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9g. Gloves, chemical resistant </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9h. Apron </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9i. Masks </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9j. Respirators (e.g., powered air purifying respirator) </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9k. Other (specify): _______________ </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr></table></td>
|
|
</tr></table></td>
|
|
</tr></table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>9l. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U</td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9m. If available, in what format were they? (<strong>Check all that apply</strong>).</p>
|
|
|
|
<p>a. ___ Verbal instructions by staff b. ___ Poster(s)</p>
|
|
<p>c. ___ Written instruction(s) d. ___ Video</p>
|
|
|
|
<p>e. ___ Other (specify): _________________________________________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>9n. Were <strong>all</strong> workers in the decontamination area dressed in appropriate PPE? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>9o. Was there inadvertent contamination of staff or victims? Y / N / U</td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9p. What issues with donning and removing PPE arose in this zone? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Broken seals b. ___ Delay in donning PPE c. ___ Improper fit</p>
|
|
|
|
<p>d. ___ Staff not trained to don PPE e. ___ Staff not trained to remove PPE f. ___ None</p>
|
|
<p>g. ___ Other (specify):_________________________________________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9q. What issues with staffing arose in this zone? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Could not communicate with each other b. ___ Fatigue c. ___ Over-heating/dehydration</p>
|
|
|
|
<p>d. ___ Inadequate numbers to allow work cycles e. ___ Other (specify): _______________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9r. How were victims screened for appropriate decontamination prior to leaving the decontamination zone? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Screening device (e.g., radiation or chemical detector)</p>
|
|
|
|
<p>b. ___ Physical examination c. ___ Not screened</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>10. Zone Disruption</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>10a. Did the zone function as planned?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><br /><br /><br /></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>10b. Was there a plan in place to relocate this zone if necessary? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr valign="top">
|
|
<td height="300"><strong>Comments</strong> (If comment refers to a specific item, give the item number.):</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p class="size2"><a href="index.html#contents">Return to Contents</a><br />
|
|
<a href="drillelementsmod2.htm">Proceed to Next Section</a></p>
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|
|
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<p> </p>
|
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<div class="footnote">
|
|
<p> The information on this page is archived and provided for reference purposes only.</p></div>
|
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