These evaluation forms are designed to help hospitals compile responses from the modules and compare data.
Pre-Drill Module / Main Module / Biological Incident Addendum / Radiological Incident Addendum
| 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 | ||||||
| C3 | Time this zone was ready to accept victims | ||||||
| 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 | ||||||
| TX1 | Time 1st victim arrived in treatment zone | ||||||
| Comments: | |||||||
| Zone Description | C6 | Picture of zone setup | |||||
| C7 | Zone location | a. Ambulance ramp | |||||
| b. Inside the hospital | |||||||
| c. Parking lot | |||||||
| d. Street/road | |||||||
| e. Other (specify) | |||||||
| C8 | Boundary for zone defined? | Y / N / U | |||||
| C9 | How defined | a. Barricade(s) | |||||
| b. Security personnel | |||||||
| c. Sign(s) | |||||||
| d. Tape | |||||||
| e. Vehicle(s) | |||||||
| f. Wall(s), permanent | |||||||
| g. Wall(s), temporary | |||||||
| 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 | |||||||
| c. Medical inpatient | |||||||
| d. Medical outpatient | |||||||
| e. Surgical inpatient | |||||||
| f. Surgical outpatient | |||||||
| 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 | |||||||
| c. Name tag | |||||||
| d. Verbal statement | |||||||
| e. Vest | |||||||
| f. Not identified | |||||||
| g. Other physical identification (specify) | |||||||
| C15 | Drill participants identifiable | Drill evaluators | |||||
| b. Drill organizers | |||||||
| c. Media | |||||||
| d. Medical personnel | |||||||
| e. Mock victims | |||||||
| 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: | |||||||