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Evaluation of Hospital Disaster Drills: A Module-Based Approach

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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Radiation Incident Addendum

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        
Time Points RA1 Time zone aware that victims affected by radiation exposure        
  Comments:        
Information Flow RA2 Means zone became aware of radiation exposed victims a. Informed by fire department        
b. Informed by ICC        
c. Onsite alarm        
d. Other (specify)        
RA3 Incident commander informed that radiation exposure was present? Y / N / U        
RA4 Method to notify incident commander a. FAX sent        
b. E-mail sent        
c. Person-to-person contact        
d. Telephone message        
e. Unclear        
f. NA        
g. Other (specify)        
RA5 Time after radiation exposure suspected that incident commander notified <30 min        
30-59 min        
1-2 hrs        
>2 hrs        
Unclear        
NA        
RA6 Radiation safety officer or designee informed that radiation present? Y / N / U        
RA7 Method to notify radiation safety officer or designee a. FAX sent        
b. E-mail sent        
c. Person-to-person contact        
d. Telephone message        
e. Unclear        
f. NA        
g. Other (specify)        
RA8 Time after radiation exposure suspected that epidemiologist or designee notified <30 min        
30-59 min        
1-2 hrs        
>2 hrs        
Unclear        
NA        
RA9 Radiation safety officer or designee provide assessment of risk associated with exposure? Y / N / U / NA        
RA10 Local and/or State health department informed that radiation exposure present? Y / N / U        
RA11 Method to notify local and/or State health department a. FAX sent        
b. E-mail sent        
c. Person-to-person contact        
d. Telephone message        
e. Unclear        
f. NA        
g. Other (specify)        
RA12 Time after radiation exposure suspected that local and/or State health department notified <30 min        
30-59 min        
1-2 hrs        
>2 hrs        
Unclear        
NA        
RA13 HAZMAT informed that radiation exposure present? Y / N / U        
RA14 Method to notify HAZMAT a. FAX sent        
b. E-mail sent        
c. Person-to-person contact        
d. Telephone message        
e. Unclear        
f. NA        
g. Other (specify)        
RA15 Time after radiation exposure suspected that HAZMAT notified <30 min        
30-59 min        
1-2 hrs        
>2 hrs        
Unclear        
NA        
RA16 Occupational health informed that radiation exposure present? Y / N / U        
RA17 Method to notify occupational health a. FAX sent        
b. E-mail sent        
c. Person-to-person contact        
d. Telephone message        
e. Unclear        
f. NA        
g. Other (specify)        
RA18 Time after radiation exposure suspected that occupational health notified <30 min        
30-59 min        
1-2 hrs        
>2 hrs        
Unclear        
NA        
RA19 Municipal wastewater treatment officials notified? Y / N / U        
  Comments:        
Materials and Supplies RA20 Prophylaxis for given agent available? Y / N / U / NA        
RA21 Specialized cleaning supplies available for contaminated equipment? Y / N / U / NA        
  Comments:        
Zone Description RA22 Radiation decontamination zone separate from triage area? Y / N / U        
RA23 Radiation decontamination zone separate from treatment area? Y / N / U        
  Integrity of boundaries assessed by use of radiation detectors        
RA24 Radiation? Y / N / U / NA        
RA25 Triage? Y / N / U / NA        
RA26 Treatment? Y / N / U / NA        
RA27 Within radiation control zone how were areas designated? a. Hot versus cold        
b. Hot versus warm versus cold        
c. No designations        
d. Other (specify)        
RA28 Decon for radiation exposure performed within hot, warm, or cold areas a. Hot        
b. Warm        
c. Cold        
d. Unclear        
e. NA        
f. Other (specify)        
  Comments:        
Safety: Isolation Precautions   Following available        
RA29 Dosimeters Y / N / U        
RA30 Floor covering Y / N / U        
RA31 Radiation signs Y / N / U        
RA32 Radiation survey meters Y / N / U        
RA33 Striped tape Y / N / U        
RA34 Radioactive and mixed waste (Bio/Rad disposal containers Y / N / U        
RA35 Other (specify) Y / N / U        
RA36 Health care workers sign in and out Y / N / U        
RA37 Entry and exit times entered a. Entry time entered        
b. Exit times entered        
c. No times entered        
d. Unclear        
RA38 Records of entry and / or exit times given to radiation safety officer? Y / N / U        
RA39 Breaches in precautions observed? (Specify in comment box) Y / N / U        
RA40 Lists of exposed and non-exposed victims generated? Y / N / U / NA        
RA41 Institutional safety officer arrive in zone to assess activity? Y / N / U / NA        
  Comments:        
Safety: Personal Protective Equipment RA42 PPE needed to protect health care workers? Y / N / U        
  Safety materials available for healthcare workers        
RA43 Passive (negative pressure) filtration Available        
Used by staff        
Adequate supply        
RA44 Powered (positive pressure) filtration Available        
Used by staff        
Adequate supply        
RA45 Self-contained breathing apparatus Available        
Used by staff        
Adequate supply        
RA46 Level B or higher suits Available        
Used by staff        
Adequate supply        
RA47 Double latex gloves Available        
Used by staff        
Adequate supply        
RA48 Face-masks with shields Available        
Used by staff        
Adequate supply        
RA49 Waterproof gowns Available        
Used by staff        
Adequate supply        
RA50 Surgical caps Available        
Used by staff        
Adequate supply        
RA51 Waterproof shoe covers Available        
Used by staff        
Adequate supply        
RA52 Other (specify) Available        
Used by staff        
Adequate supply        
RA53 Other (specify) Available        
Used by staff        
Adequate supply        
RA54 Other (specify) Available        
Used by staff        
Adequate supply        
RA55 Any observed staff without PPE interacting with contaminated victims? Y / N / U / NA        
RA56 Types of staff w/o PPE interacting with contaminated victims a. Ancillary staff        
b. Nurses        
c. Physicians        
d. Did not observe        
NA        
Other (specify)        
RA57 Dose rates to victims measured or estimated? Y / N / U        
RA58 Dose rates to staff measured or estimated? Y / N / U        
  Comments:        

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AHRQ Publication No. 04-0032
Current as of April 2004

 

The information on this page is archived and provided for reference purposes only.

 

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