California Preparedness Education Network (calPEN) – Clinic Evaluation
Template Date: October 16, 2007
Tabletop Exercise 1 or 2 (circle one) Coordinator ______Faculty ______
Clinic Name ______Clinic Contact______
Plan Status at initial meeting
(check all applicable plan components that facility has AND has made specific to their facility.
Not all components must be in place to do exercise.)
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□ ICS or HICS org chart
□ Job Action Sheets for Critical Roles
□ Hazard & vulnerability assessment
□ Risk assessment
□ EOP activation triggers
□ Internal communications process
□ External communications process
(i.e. phone tree, etc.)
□ Closure procedures/triggers
□ Process to communicate with outside
stakeholders (i.e. Public Health, security, PG&E, local CBOs, etc)
□ Shelter-in-place guidelines/triggers
□ Evacuation plan
□ EmergencyOperationsCenter forms
□EmergencyOperationsCenter procedures
□ Emergency procedures(completed CPCA/EMSA flip chart or other)
□ Pandemic influenza plan annex
□ Hazard & vulnerability assessment
□ Risk assessment
□ Other______
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Plan Status at time of TTE (check all applicable plan components)
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□ ICS or HICS org chart
□ Job Action Sheets for Critical Roles
□ Hazard & vulnerability assessment
□ Risk assessment
□ EOP activation triggers
□ Internal communications process
□ External communications process
(i.e. phone tree, etc.)
□ Closure procedures/triggers
□ Process to communicate with outside
stakeholders (Public Health, security,
PG&E, local CBO s, etc)
□ Shelter-in-place guidelines/triggers
□ Evacuation plan
□ EmergencyOperationsCenter forms
□EmergencyOperationsCenter procedures
□ Emergency procedures(completed CPCA/EMSA flip chart or other)
□ Pandemic influenza plan annex
□ Hazard & vulnerability assessment
□ Risk assessment
□ Other______
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Previous Module Presentations (circle all that apply) 1 2 3 4 5 6 TTE 1
Date of Tabletop ______Follow-up Date______
Tabletop assessment of agency (clinic capabilities): After Action Report
AGENCY CRITERIA / MET / NOT MET / N/O / N/A / Comments or Recommendations1. Describe the types of events that would lead to the activation of the emergency plan.
2. Describe the procedural steps that activate the emergency plan.
3. Describe the actions your clinic takes once the emergency plan is activated including levels and/or branches to the plan.
4. Describe the roles and responsibilities of individuals to activate the plan and carry it out.
5. Describe additional notifications needed to external agencies and activations needed in your clinic.
6. Describe how to participate in an interdisciplinary, coordinated response to an emergency.
7. Explain who is responsible for determining if the plan is being followed.
8. Explain how the person responsible will correct the plan if it is not being followed.
9. Explain the actions clinic personnel need to perform to lessen the spread of disease to staff, patients and family members.
10. Describe how clinic will handle surge of infectious patients and maintain infection control practices.
N/O = Not observedN/A = Not Applicable to this site\
What strengths were identified: (specify)
In the policies and procedures
______
Relating to the personnel
______
In accessing needed resources both internal and external
______
Relating to communication with residents, families, among the staff and external
stakeholders
______
Within the community
______
What weaknesses were identified: (specify)
In the policies and procedures
______
Relating to the personnel
______
In accessing needed resources, both internal and external
______
Relating to communication with residents, families, among the staff and external stakeholders
______
Within the community
______
Corrective After Action Plan Ranking
Please rank and list above corrective actions along with actions to be taken to complete these corrective measures. These rankings should be based from the weaknesses listed above. Personnel in charge of the corrective action must be identified.
Corrective Action Timeline
Briefly outline the time frame for the corrective action to take place base d on the priority ranking listed above. Action Plan for Improvements: (specify)
Description of actions to be taken
______
Assignments
______
Associated costs and budget
______
Timetable for completion
______
Follow-up responsibility
______
Disaster Preparedness Contacts
Public Health Disaster Preparedness Coordinator:
Local Hospital Disaster Coordinator:
Local EMS Agency Coordinator:
Cal-PEN coordinator:
California Primary Care Association link:
Cal-Pen faculty advisor:
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