Emergency Plan Manual

EMERGENCY EXERCISE EVALUATION FORM Page 1 of 3 EMERGENCY EXERCISE or EVENT EVALUATION FORM Background Information Date of Exercise or Event Staff Coordinating Exercise or Event Response Type of Exercise or Event Describe: • Exercise or Actual Emergency? Exercise ______ Actual Emergency _____ • Community-wide experience? No _____ Yes (describe)__________________________________ • Include influx of actual or simulated patients? No _____ Yes (describe) __________________________________ Location(s) Services Included Estimated start time of exercise/event Estimated end time of exercise/event Note Taker Other – specify EXERCISE or EVENT EVALUATION Core Areas: Yes Partial No N/A Comments EVENT NOTIFICATION Activation of the emergency management all hazards command structure Notification of staff Notification of external authorities Other - specify: COMMUNICATION Within the office With response entities outside of the agency such as local authority responsible for coordinating community response With back-up agency(ies) Backup internal and external communication systems in the event of failure during emergencies With staff With contract staff With patients/families Other - specify: RESOURCE MOBILIZATION AND ALLOCATION Responders Identifying care providers and other personnel Assigning staff to cover essential functions Equipment & Supplies Personal protective equipment Transportation Coordination among organization’s programs Security Other - specify: SAFETY AND SECURITY Access Traffic control