Tornado Response Checklist & Drill Evaluation Form 2016 / The University of Kansas Hospital
Date: / ___ /___ /___
M / D / Y / Shift: /  shift1
 shift2
 shift3 / Time
All Clear / ___ : ___
AMPM
___ : ___
AMPM /  / OFFSITE
List your location
below / 



 / Bell drill
Heart drill
Delp drill
Olathe drill
Other______
Department: / ______/ Floor: / ______
Was tornado simulated ______
Section 1 – Tornado Watch / Action Performed /
The Department Director, Manager, or designee of each non-nursing unit or department will inform staff that a Tornado Watch has been issued. /

Y N

/ N/A
Using discretion, inform patients and visitors of the threat of inclement weather. /

Y N

/ N/A
Assess the mobility of employees and visitors in the unit or department, recognize the need to assist those with special needs, and be prepared for moving into tornado safe areas should the tornado watch turn into a tornado warning. /

Y N

/ N/A
Ensure that hallways are clear. /

Y N

/ N/A
Secure patient belongings (e.g., shoes, clothing) with each patient. /

Y N

/ N/A
Assess linen supply and obtain extra blankets and pillows as needed for immobile patients who cannot or should not be moved from their rooms. /

Y N

/ N/A
A surgical mask should be made available for patients under airborne precautions. /

Y N

/ N/A
Confirm location of department disaster bin and working flashlights. /

Y N

/ N/A
Close curtains/blinds in offices and conference rooms. /

Y N

/ N/A
Check red emergency back-up phone for dial tone and attached phone list. /

Y N

/ N/A
Evaluate the need for additional equipment and resources such as portable ventilators and respiratory therapists. /

Y N

/ N/A
Stay in your area /

Y N

/ N/A
Section 2 – Tornado Warning / Action Performed /
When a Tornado Warning is announced begin moving patients and visitors to “tornado safe” areas. Keep as many walls between you and the outside as possible. /

Y N

/ N/A
Do not use elevators. /

Y N

/ N/A
Walk, Wheel Chair, and Bed patients should be directed or moved into the interior core hallways of the nursing unit, away from exterior windows and glass. Shut the door to the patient’s room. Take chairs to hallway as needed. /

Y N

/ N/A
Protect-in-Place patients should be protected in place by moving the beds away from windows with curtains closed and patients’ heads protected with pillows and/or blankets. /

Y N

/ N/A
A surgical mask should be placed on patients under airborne precautions before moving them out of their rooms. /

Y N

/ N/A
Visitors should be directed to the most interior core of the unit away from exterior windows and glass. /

Y N

/ N/A
Patients en-route from one area to another should be taken to the nearest “tornado safe area” until the “Tornado Warning All Clear” is given. /

Y N

/ N/A
Remain in the “tornado safe” areas until the “Tornado Warning All Clear” has been announced. /

Y N

/ N/A
Department disaster bins may be accessed as necessary. Department Directors/Managers are responsible for working with Materials Management liaisons to restock and reseal disaster bins after use. /

Y N

/ N/A
Extension tubing or oxygen cylinders should be used to insure the continued delivery of medical gases. /

Y N

/ N/A
Determine a suitable tornado safe area with adequate medical gases and power supply prior to moving patients on life support. /

Y N

/ N/A
Stay in your assigned area. /
Section 3 – Identify Tornado Safe Area / Action Performed /
Interior center core hallways, offices, bathrooms, and closets on all levels away from windows and glass /

Y N

/ N/A
Enclosed stairwells without glass (stay to one side single file) / Y N / N/A
Basement level (Form a line single file along each side of hallways) / Y N / N/A
Interior center core hallways, offices, bathrooms, and closets on all levels away from windows and glass / Y N / N/A

Department Manager: ______Title: ______Phone #______

Department Representative: ______Title: ______Phone #______

Summary of drill/ Observations*

Was your department alerted with a Tornado Watch? Y N N/A

Was your department alerted with a Tornado Warning? Y N N/A

Did you department complete the tornado response checklist? Y N N/A

Did your department understand what to do in the event of a Tornado Warning? Y N N/A

Do you know where your Tornado Safe Area is located? Y N N/A

______

*Observations:

The Department Manager is responsible for addressing departmental areas for improvement and submitting a corrective action plan and to the EOC department.

Name (Print) / Signature / Department

RECORD NAMES OF PARTICIPANTS