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Administrator's Guide

Public Health Emergency Preparedness

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.

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Appendix B. Questionnaire Mapping Document

Column # Column ID Question Category Question # Question Additional Question Column Value Answer Sub Link to Column
1 Survey ID Demographic sys (system)           Survey ID
2 Begin Time Demographic sys (system)           Begin Time
3 End Time Demographic sys (system)           End Time
4 D01 Demographic Demo Hospital Name   Varchar     D01
5 D02 Demographic Demo Street Address   Varchar     D02
6 D03 Demographic Demo City   Varchar     D03
7 D04 Demographic Demo State   Varchar     D04
8 D05 Demographic Demo Zip   Varchar     D05
9 D06 Demographic Demo Telephone Number of primary contact   Varchar     D06
10 D07 Demographic Demo Primary Contact for this Survey   Varchar     D07
11 D08 Demographic Demo Title of Primary Contact   Varchar     D08
12 D09 Demographic Demo Telephone Number of primary contact   Varchar     D09
13 D10 Demographic Demo E-mail address of primary contact   Varchar     D10
14 D11 Demographic Demo Licensed beds   int     D11
15 D12 Demographic Demo Staffed beds   int     D12
16 D13 Demographic Demo Funds   Varchar     D13
17 D14 Demographic Demo Funding agency   Varchar     D14
18 D15 Demographic Demo In kind   Varchar     D15
19 D16 Demographic Demo Trauma   True/False Yes/No   D16
20 D17A Demographic Demo General medical, surgical   True/False Yes/No   D17A
21 D17B Demographic Demo Burn center   True/False Yes/No   D17B
22 D17C Demographic Demo Trauma center   True/False Yes/No   D17C
23 D17D Demographic Demo Psychiatric   True/False Yes/No   D17D
24 D17E Demographic Demo Children's   True/False Yes/No   D17E
25 D17F Demographic Demo Long-term care/skilled nursing facility   True/False Yes/No   D17F
26 D17G Demographic Demo Rehabilitation   True/False Yes/No   D17G
27 D17H Demographic Demo Other   True/False Yes/No   D17H
28 D18 Demographic Demo Type of hospital   1 Rural (non-Metropolitan Statistical Area (MSA)) hospital   D18
2 Urban (MSA) hospital   D18
3 Don't know   D18
29 D19 Demographic Demo Type of hospital   1 Private for-profit   D19
2 Private not-for-profit   D19
3 Military   D19
4 Veterans Administration   D19
5 Indian Health Service   D19
6 Other public (Federal, State, local government)   D19
7 Other   D19
30 D20 Demographic Demo Is your hospital an academic/teaching facility?   True/False Yes/No   D20
31 D21 Demographic Demo Is your hospital in a network or system with other hospitals?   True/False Yes/No   D21
32 Q01 Administration and Planning 1 Has the hospital designated a coordinator (or group/committee) who is responsible for overseeing all of the hospital's chemical, biological, radiological, nuclear, and explosive events (CBRNE) preparedness efforts?   1 No, and not planned within the next 6 months.   Q01
2 No, but the hospital plans to designate a coordinator within the next 6 months.   Q01
3 Yes.   Q01
4 Other.   Q01
33 Q02 Administration and Planning 2 Has the hospital designated a medical director (or group) for its CBRNE preparedness efforts?   1 No, and not planned within the next 6 months.   Q02
2 No, but the hospital plans to designate a medical director within the next 6 months.   Q02
3 Yes.   Q02
4 Other.   Q02
34 Q03 Administration and Planning 3 Does the hospital use an Incident Command System (ICS) to manage events that impact normal operations?   1 No, and not planned within the next 6 months.   Q03
2 No, but the hospital plans to use an ICS within the next 6 months.   Q03
3 ICS is currently being developed.   Q03
4 Yes, but all hospital staff are not trained on their roles in the system.   Q03
5 Yes, and all hospital staff are trained on their roles in the system.   Q03
6 Other.   Q03
35 Q034A Administration and Planning 3 Is the ICS used on a near daily basis to manage events that impact normal operations?   True/False Yes/No Y Q034A
36 Q034B 3 Is the ICS practiced routinely in exercises/drills?   True/False Yes/No Y Q034B
37 Q034C 3 Is the ICS updated as needed after exercises/drills?   True/False Yes/No Y Q034C
38 Q034D 3 Is the ICS incorporated into existing training programs?   True/False Yes/No Y Q034D
39 Q034E 3 Is the ICS formally incorporated into the emergency operations plan (EOP)?   True/False Yes/No Y Q034E
40 Q034F 3 Is the ICS coordinated with local entities?   True/False Yes/No Y Q034F
41 Q04 Administration and Planning 4 Has the hospital designated an individual to manage and maintain its decontamination capability?   1 No, and not planned within the next 6 months.   Q04
2 No, but planned within the next 6 months.   Q04
2 Yes, and their responsibilities include (check all that apply):   Q04
4 Other.   Q04
42 Q043A Administration and Planning 4 Inspecting, inventorying, storing, and purchasing personal protective equipment (PPE) when needed.   True/False Yes/No Y Q043A
43 Q043B 4 Upkeep and maintenance of the decontamination equipment.   True/False Yes/No Y Q043B
44 Q043C 4 Maintenance of training records.   True/False Yes/No Y Q043C
45 Q043D 4 Ongoing training.   True/False Yes/No Y Q043D
46 Q043E 4 Recruitment of new team members.   True/False Yes/No Y Q043E
47 Q043F 4 Maintenance of exposure records.   True/False Yes/No Y Q043F
48 Q05 Administration and Planning 5 Does the hospital have a plan for a CBRNE event that is reviewed and updated?   1 No, and not planned within the next 6 months.   Q05
2 No, but the hospital intends to begin to draft a CBRNE plan within the next 6 months.   Q05
3 The plan is currently being drafted.   Q05
4 Yes, the plan includes the following but is not updated every 2 years.   Q05
5 Yes, the plan includes the following and is updated at least 2 years.   Q05
6 Other.   Q05
49 Q54A Administration and Planning 5 Hospital's roles and responsibilities in a community CBRNE event   True/False Yes/No Y Q54A
50 Q54B 5 Scenario in which the hospital itself is the target of a CBRNE event   True/False Yes/No Y Q54B
51 Q54C 5 Plan activation and staff notification procedures   True/False Yes/No Y Q54C
52 Q54D 5 Shelter in place   True/False Yes/No Y Q54D
53 Q54E 5 Evacuation   True/False Yes/No Y Q54E
54 Q54F 5 Initial recognition and presumptive diagnosis of symptomatic CBRNE patients   True/False Yes/No Y Q54F
55 Q54G 5 Communication to and notification of staff of suspected CBRNE cases   True/False Yes/No Y Q54G
56 Q54H 5 Diagnostic procedures or tests to make presumptive diagnosis   True/False Yes/No Y Q54H
57 Q54I 5 Means to access age-specific CBRNE medical management guidelines from the public health departments and other appropriate agencies   True/False Yes/No Y Q54I
58 Q54J 5 Provision of mental health services for affected patients   True/False Yes/No Y Q54J
59 Q54K 5 Provision for controlling hospital access to limit contamination of the facility and individuals   True/False Yes/No Y Q54K
60 Q54L 5 Capability to isolate CBRNE patients from general inpatient population   True/False Yes/No Y Q54L
61 Q54M 5 Capability to isolate CBRNE patients from general outpatient population   True/False Yes/No Y Q54M
62 Q54N 5 Provisions for handling suspected CBRNE agents brought to the hospital or sampled within the hospital   True/False Yes/No Y Q54N
63 Q54O 5 Patient care expansion areas usable for assessing and treating potential victims of CBRNE events   True/False Yes/No Y Q54O
64 Q54P 5 Memorandums of understanding with external treatment facilities for overflow in the event of treatment site contamination or capacity shortages   True/False Yes/No Y Q54P
65 Q54Q 5 Receipt and management of surge caches of pharmaceuticals and supplies   True/False Yes/No Y Q54
66 Q54R 5 Means to access additional supplies of blood and blood products   True/False Yes/No Y Q54R
67 Q54S 5 Follow up instructions for patients and their home care providers that consider published guidelines from public health departments or the Centers for Disease Control and Prevention (CDC)   True/False Yes/No Y Q54S
68 Q54T 5 Cost recovery plan coordinated with third party payers   True/False Yes/No Y Q54T
69 Q54U 5 After-action evaluation of hospital's response to CBRNE event   True/False Yes/No Y Q54U
70 Q54V 5 Disaster Recovery Procedures   True/False Yes/No Y Q54V
71 Q06 Administration and Planning 6 Are funds for CBRNE preparedness (i.e., planning, training, operations, etc.) included into the hospital's budget?   1 No, and not planned within the next 6 months. Y Q06
2 No, but the hospital plans to include CBRNE preparedness funds into the budget within the next 6 months. Y Q06
3 Budgetary items are currently being evaluated. Y Q06
4 Yes, but only those received from NBHPP. Y Q06
5 Yes, and there are funds over and above those received from NBHPP. Y Q06
6 Other. Y Q06
72 Q07 Administration and Planning 7 Does the hospital participate in a regional planning group (i.e., local/State public health department) or other groups responsible for regional CBRNE preparedness?   1 No, and not planned within the next 6 months. Y Q07
2 No, but the hospital plans to participate in a regional planning group within the next 6 months. Y Q07
3 Involvement in a regional planning group is being considered. Y Q07
4 Yes, but there is relatively infrequent interaction between the regional planning group and the hospital. Y Q07
5 Yes, and there is ongoing interaction between the regional planning group and the hospital. Y Q07
6 Other Y Q07
73 Q074A Administration and Planning 7 Hospitals in local area   True/False Y/N Y Q074A
74 Q074B 7 Department of Homeland Security   True/False Y/N Y Q074B
75 Q074C 7 Health department   True/False Y/N Y Q074C
76 Q074D 7 Local emergency planning committee   True/False Y/N Y Q074D
77 Q074E 7 Local fire department   True/False Y/N Y Q074E
78 Q074F 7 Local emergency medical service(s) (EMS)   True/False Y/N Y Q074F
79 Q074G 7 Local law enforcement   True/False Y/N Y Q074G
80 Q074H 7 Other (please list)   True/False Y/N Y Q074H
81 Q08 Education and Training 8 Does the hospital provide competency-based training on CBRNE events to clinical staff?   1 No, and not planned within the next 6 months.   Q08
2 No, but hospital plans to provide competency-based training to clinical staff within the next 6 months.   Q08
3 Some clinical staff has been trained.   Q08
4 Yes, all clinical staff has been trained, but less frequently than every 2 years.   Q08
5 Yes, all clinical staff is trained at least every 2 years.   Q08
6 Other.   Q08
82 Q09 Education and Training 9 Does the hospital provide competency-based training on CBRNE events to non-clinical staff?   1 No, and not planned within the next 6 months.   Q09
2 No, but hospital plans to provide competency-based training to non-clinical staff within the next 6 months.   Q09
3 Some non-clinical staff have been trained.   Q09
4 Yes, all non-clinical staff have been trained, but less frequently than every 2 years.   Q09
5 Yes, all non-clinical staff are trained at least every 2 years.   Q09
6 Other.   Q09
83 Q10 Education and Training 10 Does the hospital provide training in accordance with Occupational Safety and Health Administration (OSHA) standards to personnel who may be part of the decontamination response?   1 No, and not planned within the next 6 months.   Q10
2 No, but the hospital plans to provide training according to OSHA standards within the next 6 months.   Q10
3 Training curriculum is currently being developed.   Q10
4 Yes, training on the following is provided, but not on an annual basis.   Q10
5 Yes, and training on the following is provided annually.   Q10
6 Other.   Q10
84 Q104A1 Education and Training 10 OSHA-level operations training for all staff with designated roles in the hospital decontamination zone (area where contamination may be found and decontamination performed) Conducted training True/False Yes/No Y Q104A1
85 Q104A2 10 OSHA-level operations training for all staff with designated roles in the hospital decontamination zone (area where contamination may be found and decontamination performed) Tested in Exercise/drill True/False Yes/No Y Q104A2
86 Q104B1 Education and Training 10 OSHA-level awareness training for all staff assigned to areas proximate to the decontamination zone where contact with contaminated may occur Conducted training True/False Yes/No Y Q104B1
87 Q104B2 10 OSHA-level awareness training for all staff assigned to areas proximate to the decontamination zone where contact with contaminated may occur Tested in Exercise/drill True/False Yes/No Y Q104B2
88 Q104C1 Education and Training 10 Agent identification Conducted training True/False Yes/No Y Q104C1
89 Q104C2 10 Agent identification Tested in Exercise/drill True/False Yes/No Y Q104C2
90 Q104D1 Education and Training 10 Selection and use of PPE Conducted training True/False Yes/No Y Q104D1
91 Q104D2 10 Selection and use of PPE Tested in Exercise/drill True/False Yes/No Y Q104D2
92 Q104E1 Education and Training 10 Decontamination area setup Conducted training True/False Yes/No Y Q104E1
93 Q104E2     Decontamination area setup Tested in Exercise/drill True/False Yes/No Y Q104E2
94 Q104F1 Education and Training 10 Patient decontamination Conducted training True/False Yes/No Y Q104F1
95 Q104F2 10 Patient decontamination Tested in Exercise/drill True/False Yes/No Y Q104F2
96 Q104G1 Education and Training 10 Decontamination area cleanup Conducted training True/False Yes/No Y Q104G1
97 Q104G2 10 Decontamination area cleanup Tested in Exercise/drill True/False Yes/No Y Q104G2
98 Q104H1 Education and Training 10 Radiation contamination/exposure management Conducted training True/False Yes/No Y Q104H1
99 Q104H2 10 Radiation contamination/exposure management Tested in Exercise/drill True/False Yes/No Y Q104H2
100 Q104I1 Education and Training 10 Equipment inspection, maintenance, and storage Conducted training True/False Yes/No Y Q104I1
101 Q104I2 10 Equipment inspection, maintenance, and storage Tested in Exercise/drill True/False Yes/No Y Q104I2

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