______MedicalCenter

DISASTER MONITOR

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Hazard Vulnerability Analysis:Score: _____ of 5

YesNoN/A

1.Hazard Vulnerability Analysis Element tested: 

Describe HVA element tested:

CommandCenter:Score: _____ of 5

YesNoN/A

1.Was proper alert paged?

2.Was Incident Command System activated appropriately?

3.Was the CommandCenter used & staffed?

4.Were job action sheets assigned within 10 minutes?

5.Did affected departments report in to appropriate Section

Chiefs in a timely manner?

6.Was the “all clear” paged?

7.Did each department respond appropriately & per policy?

Comments:

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Emergency Supplies & Systems:Score: _____ of 5

YesNoN/A

1.Were emergency supplies (including equipment) readily available & adequate?   

2.Was it necessary to procure supplies from another source?

3.Did all emergency systems function correctly?

4.Was it necessary to bring in outside vendors/contractors?

5.Was equipment damaged or loaned out during the event

appropriately identified and reported?

Comments:

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Security / Facility:Score: _____ of 5

YesNoN/A

1.Was adequate security provided?

2.Was the building secured / locked down?

3.Were all staff & volunteers appropriately identified?

4.Was traffic control established & enforced?

5.Were emergency vehicles and personnel able to access

emergency services?

6.Were unauthorized persons kept away from the incident

scene?

7.Was there contact / coordination with outside agencies,

i.e. law enforcement, fire department, etc?

8.Was property damage reported to the CommandCenter?

9.Were alternate care sites, either within or outside of the

hospital, utilized?

  1. Was there a loss of utilities or other function during the

during the event? If yes, describe briefly: ______

10.Was there appropriate management of loss of facility

function?

Comments:

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Patient Care:Score: _____ of 5

YesNoN/A

1.Were provisions for the management of patients, including

scheduling of services, control of patient information,

admission, transfer, and discharge adequate?

  1. Were all patients identified, accounted for, triaged &

prioritized?

3.Was all necessary medical treatment available & adequate?

4.Were the needs of patients and family members addressed?

Comments:

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Information and Communication Systems:Score: _____ of 5

YesNoN/A

1.Was the correct code paged and heard?

2.Were emergency communications set up as needed?

3.Was a spokesperson designated for press & family info?

4.Was the call list implemented and up to date?

5.Appropriate internal staff notified?

6.Appropriate external staff notified?

7.Were community Emergency Response Agency efforts

incorporated / coordinated? (community-wide test)

8.Was switchboard able to handle / route outside calls

appropriately?

9.Was patient information appropriately communicated to the

Admitting Office?

  1. Were communications within the hospital appropriate and

effective?

  1. Were communications with external response entities

appropriate and effective?

Comments:

Date: Time: Submitted by: ______

HazMat incidentRadiationInfant / Pedi Abduction

Security breachSevere WeatherMajor Utility Disruption

Mass CasualtyMissing PersonSnow Emergency

Bomb Hostage / Aggressor Evacuation

Civil DisturbanceCommunity-wideOther: ______

Staffing & Emergency Response:Score: _____ of 5

YesNoN/A

1.Were provisions for the management of staff, including

distribution and assignment of responsibilities and

functions adequate?

2.Was there adequate staffing?

3.Were recall lists utilized?

4.Did staff display adequate knowledge of their roles /

responsibilities during emergency?

5.Were the needs of staff & their dependents addressed?

6.Were staff injuries and/or exposures addressed?

7.Were time sheets for off duty staff managed appropriately?

8.Was PPE utilized and adequate?

Comments:

Please rate the performance of this response element on a scale of 0 to 5:

5 – All components executed correctly

4 – Only minor issues noted

3 – Most expectations met; some significant issues noted

2 – Most expectations not met; many significant issues noted

1 – Obvious lack of staff knowledge / motivation

0 – No components executed correctly

Element in “bold” font represents a core performance area.