Emergency Plan Manual

EMERGENCY EXERCISE EVALUATION FORM Page 2 of 3 Core Areas: Yes Partial No N/A Comments STAFF RESPONSIBILITIES Incident Commander/Team Activities related to care, treatment, and services (for example, scheduling, modifying, or discontinuing services; controlling information about patients; referrals; transporting patients) Alternative staff roles and responsibilities of staff (i.e., whom they report to) Use of personal protective equipment Staff rotation Staff aware of their roles Staff support activities (for example, housing, transportation, incident stress debriefing) Staff family support activities Other - specify: UTILITIES MANAGEMENT Alternative means of meeting essential building utility needs (for example, electricity, water, heating/air conditioning, fuel sources) Other - specify: PATIENT MANAGEMENT Patient acuity assignment accurate Availability of patient emergency contact info. Processes related to triage activities Provision of care Daily patients seen or knew what to do Patient identification & tracking processes OTHER Able to be self-sufficient for 96 hours? Adequacy of business continuity plan: Other - specify: Other - specify: EVACUATION Evacuating the building Alternate site available For agencies who have patients treated at the organization’s site: Alternative Care Site – • transporting patients, staff, and equipment to the alternative care site(s) • Transferring to and from the alternative care site(s), the necessities of patients (for example, medications, medical records) • Tracking of patients • Interfacility communication between the agency and the alternative care site(s) Other - specify: