These evaluation forms are designed to help hospitals compile responses from
the modules and compare data.
| Hospital |
# |
Question |
Incident Command Center |
Decontamination |
Triage |
Treatment |
| Section |
| Observer Information |
|
Date |
|
|
|
|
| Observer name |
|
|
|
|
| Observer title |
|
|
|
|
| Time period of evaluation |
|
|
|
|
| |
10 triage |
|
|
|
|
| |
20 triage |
|
|
|
|
| |
NA |
|
|
|
|
| Time Points |
C1 |
Drill began |
|
|
|
|
| C2 |
Disaster plan initiated in zone |
|
|
|
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| C3 |
Time this zone was ready to accept victims |
|
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|
|
| C4 |
Time zone notified that ICC operational |
|
|
|
|
| C5 |
Drill ended in zone |
|
|
|
|
| DE1 |
Time 1st victim arrived at decon zone |
|
|
|
|
| TG1 |
Time 1st victim arrived at triage zone |
|
|
|
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| TX1 |
Time 1st victim arrived in treatment zone |
|
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|
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| |
Comments: |
|
|
|
|
| Zone Description |
C6 |
Picture of zone setup |
|
|
|
|
| C7 |
Zone location |
a. Ambulance ramp |
|
|
|
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| b. Inside the hospital |
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|
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| c. Parking lot |
|
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|
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| d. Street/road |
|
|
|
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| e. Other (specify) |
|
|
|
|
| C8 |
Boundary for zone defined? |
Y / N / U |
|
|
|
|
| C9 |
How defined |
a. Barricade(s) |
|
|
|
|
| b. Security personnel |
|
|
|
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| c. Sign(s) |
|
|
|
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| d. Tape |
|
|
|
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| e. Vehicle(s) |
|
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|
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| f. Wall(s), permanent |
|
|
|
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| g. Wall(s),
temporary |
|
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|
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| h. No boundary |
|
|
|
|
| i. Other (specify) |
|
|
|
|
| C10 |
Were providers able to move easily through this zone? |
Y / N / U |
|
|
|
|
| DE2 |
Type area used for decon |
a. Covered designated outdoor decon area |
|
|
|
|
| b. Open outdoor decon area |
|
|
|
|
| c. Designated indoor decon area; specify
# rooms |
|
|
|
|
| d. Other (specify) |
|
|
|
|
| DE3 |
Distance EMS offload to decon area (ft) |
|
|
|
|
| TG2 |
Triage zone contiguous to or located in emergency
department (ED) |
Y / N / U |
|
|
|
|
| TG3 |
Distance away if not contiguous (ft) |
|
|
|
|
| TX2 |
Type of unit during day to day activities |
a. ED |
|
|
|
|
| b. Intensive care |
|
|
|
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| c. Medical inpatient |
|
|
|
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| d. Medical outpatient |
|
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|
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| e. Surgical inpatient |
|
|
|
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| f. Surgical outpatient |
|
|
|
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| g. Other (specify) |
|
|
|
|
| TX3 |
Location of unit (e.g. floor) |
|
|
|
|
| TX4 |
Actual patients treated
in drill treatment area |
Y / N / U |
|
|
|
|
| |
Comments: |
|
|
|
|
| Personnel |
C11 |
Someone in charge of zone? |
Y / N / U |
|
|
|
|
| C12 |
Minutes after drill activity began in zone
that person took charge |
<10 min |
|
|
|
|
| 10-29 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| No one |
|
|
|
|
| C13 |
Officially designated person? |
Y / N / U / NA |
|
|
|
|
| C14 |
How person in charge of zone identified |
a. Arm band |
|
|
|
|
| b. Hat |
|
|
|
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| c. Name tag |
|
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|
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| d. Verbal statement |
|
|
|
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| e. Vest |
|
|
|
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| f. Not identified |
|
|
|
|
| g. Other physical identification (specify) |
|
|
|
|
| C15 |
Drill participants identifiable |
Drill evaluators |
|
|
|
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| b. Drill organizers |
|
|
|
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| c. Media |
|
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|
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| d. Medical personnel |
|
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|
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| e. Mock victims |
|
|
|
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| f. Observers |
|
|
|
|
| g. Security |
|
|
|
|
| |
Number of hospital participants initially
assigned to this zone? |
|
|
|
|
| C16 |
Physicians |
# |
|
|
|
|
| C17 |
Nurses |
# |
|
|
|
|
| C18 |
Ancillary personnel |
# |
|
|
|
|
| C19 |
Additional drill participants added? |
Y / N / U |
|
|
|
|
| |
Approximate number of additional staff |
|
|
|
|
| C20 |
Physicians |
# |
|
|
|
|
| C21 |
Nurses |
# |
|
|
|
|
| C22 |
Ancillary personnel |
# |
|
|
|
|
| IC1 |
First took charge of zone? (name and title) |
|
|
|
|
| IC2 |
Minutes after drill start that designated
incident commander arrived |
<10 min |
|
|
|
|
| 10-20 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Never arrived |
|
|
|
|
| IC3 |
Members of incident command identifiable? |
(Y / N / U) |
|
|
|
|
| |
Someone filling functions of following
roles or reporting to ICC? |
|
|
|
|
| IC4 |
Incident Commander |
Y / N / U / NA Comments |
|
|
|
|
| IC5 |
Public Information Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC6 |
Liaison Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC7 |
Safety and Security Officer |
Y / N / U / NA Comments |
|
|
|
|
| IC8 |
Logistics Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC9 |
Facilities Management Unit |
Y / N / U / NA Comments |
|
|
|
|
| IC10 |
Communications Unit |
Y / N / U / NA Comments |
|
|
|
|
| IC11 |
Patient Transport Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC12 |
Material/Supply Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC13 |
Nutritional Supply Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC14 |
Planning Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC15 |
Labor Pool Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC16 |
Medical Staff Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC17 |
Nursing Unit Leader |
Y / N / U / NA Comments |
|
|
|
|
| IC18 |
Finance Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC19 |
Operations Chief |
Y / N / U / NA Comments |
|
|
|
|
| IC20 |
Medical Care Director |
Y / N / U / NA Comments |
|
|
|
|
| IC21 |
Ancillary Services |
Y / N / U / NA Comments |
|
|
|
|
| IC22 |
Human Services Director |
Y / N / U / NA Comments |
|
|
|
|
| IC23 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| IC24 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| IC25 |
Other (specify) |
Y / N / U / NA Comments |
|
|
|
|
| TG4 |
Anyone perform triage independently and without authority? |
Y / N / U |
|
|
|
|
| |
Comments: |
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540 Gaither Road Rockville, MD 20850