Emergency Preparedness Survey
Exit this survey
1. Self Evaluation - Emergency Preparedness and Safety
As part of the decision making basis for emergency preparedness education and support for the home care industry, we're doing a brief survey of the level of agency's perceived levels of preparedness in different areas as well as education practices.
1
. Optional
Optional
Name:
Company:
Title:
Address:
City/Town:
ZIP:
Email Address:
Phone Number:
2
. Please assess your agency's overall level of preparedness from a level of zero (not at all) to a level of ten (well prepared) for each category to the best of your ability.
0
1
2
3
4
5
6
7
8
9
10
Surge Capacity
*
Please assess your agency's overall level of preparedness from a level of zero (not at all) to a level of ten (well prepared) for each category to the best of your ability. Surge Capacity 0
Surge Capacity 1
Surge Capacity 2
Surge Capacity 3
Surge Capacity 4
Surge Capacity 5
Surge Capacity 6
Surge Capacity 7
Surge Capacity 8
Surge Capacity 9
Surge Capacity 10
Pandemic Flu
Pandemic Flu 0
Pandemic Flu 1
Pandemic Flu 2
Pandemic Flu 3
Pandemic Flu 4
Pandemic Flu 5
Pandemic Flu 6
Pandemic Flu 7
Pandemic Flu 8
Pandemic Flu 9
Pandemic Flu 10
Flood/Hurricane
Flood/Hurricane 0
Flood/Hurricane 1
Flood/Hurricane 2
Flood/Hurricane 3
Flood/Hurricane 4
Flood/Hurricane 5
Flood/Hurricane 6
Flood/Hurricane 7
Flood/Hurricane 8
Flood/Hurricane 9
Flood/Hurricane 10
Snow/Ice Storm
Snow/Ice Storm 0
Snow/Ice Storm 1
Snow/Ice Storm 2
Snow/Ice Storm 3
Snow/Ice Storm 4
Snow/Ice Storm 5
Snow/Ice Storm 6
Snow/Ice Storm 7
Snow/Ice Storm 8
Snow/Ice Storm 9
Snow/Ice Storm 10
Transit Strike/Transportation Problem (road closure, etc.)
Transit Strike/Transportation Problem (road closure, etc.) 0
Transit Strike/Transportation Problem (road closure, etc.) 1
Transit Strike/Transportation Problem (road closure, etc.) 2
Transit Strike/Transportation Problem (road closure, etc.) 3
Transit Strike/Transportation Problem (road closure, etc.) 4
Transit Strike/Transportation Problem (road closure, etc.) 5
Transit Strike/Transportation Problem (road closure, etc.) 6
Transit Strike/Transportation Problem (road closure, etc.) 7
Transit Strike/Transportation Problem (road closure, etc.) 8
Transit Strike/Transportation Problem (road closure, etc.) 9
Transit Strike/Transportation Problem (road closure, etc.) 10
Evacuation Planning
Evacuation Planning 0
Evacuation Planning 1
Evacuation Planning 2
Evacuation Planning 3
Evacuation Planning 4
Evacuation Planning 5
Evacuation Planning 6
Evacuation Planning 7
Evacuation Planning 8
Evacuation Planning 9
Evacuation Planning 10
Bioterrorism
Bioterrorism 0
Bioterrorism 1
Bioterrorism 2
Bioterrorism 3
Bioterrorism 4
Bioterrorism 5
Bioterrorism 6
Bioterrorism 7
Bioterrorism 8
Bioterrorism 9
Bioterrorism 10
Chemical/Radiological Emergency
Chemical/Radiological Emergency 0
Chemical/Radiological Emergency 1
Chemical/Radiological Emergency 2
Chemical/Radiological Emergency 3
Chemical/Radiological Emergency 4
Chemical/Radiological Emergency 5
Chemical/Radiological Emergency 6
Chemical/Radiological Emergency 7
Chemical/Radiological Emergency 8
Chemical/Radiological Emergency 9
Chemical/Radiological Emergency 10
Explosion
Explosion 0
Explosion 1
Explosion 2
Explosion 3
Explosion 4
Explosion 5
Explosion 6
Explosion 7
Explosion 8
Explosion 9
Explosion 10
IT failure
IT failure 0
IT failure 1
IT failure 2
IT failure 3
IT failure 4
IT failure 5
IT failure 6
IT failure 7
IT failure 8
IT failure 9
IT failure 10
Communications Failure
Communications Failure 0
Communications Failure 1
Communications Failure 2
Communications Failure 3
Communications Failure 4
Communications Failure 5
Communications Failure 6
Communications Failure 7
Communications Failure 8
Communications Failure 9
Communications Failure 10
Other (please specify)
3
. How frequently do you provide emergency preparedness training to your staff?
At Orientation
Annually
Every two years
Other
N/A
Professional
*
How frequently do you provide emergency preparedness training to your staff? Professional At Orientation
Professional Annually
Professional Every two years
Professional Other
Professional N/A
Paraprofessional
Paraprofessional At Orientation
Paraprofessional Annually
Paraprofessional Every two years
Paraprofessional Other
Paraprofessional N/A
Administrative
Administrative At Orientation
Administrative Annually
Administrative Every two years
Administrative Other
Administrative N/A
Other (please specify)
4
. What type of safety training do you offer your staff?
Professional Staff
Paraprofessional Staff
Administrative Staff
General safety
*
What type of safety training do you offer your staff? General safety Professional Staff
General safety Paraprofessional Staff
General safety Administrative Staff
Safety in the home
Safety in the home Professional Staff
Safety in the home Paraprofessional Staff
Safety in the home Administrative Staff
Safety during specific types of disasters (hurricanes, bio terrorism, etc.)
Safety during specific types of disasters (hurricanes, bio terrorism, etc.) Professional Staff
Safety during specific types of disasters (hurricanes, bio terrorism, etc.) Paraprofessional Staff
Safety during specific types of disasters (hurricanes, bio terrorism, etc.) Administrative Staff
We do not provide safety training to our staff
We do not provide safety training to our staff Professional Staff
We do not provide safety training to our staff Paraprofessional Staff
We do not provide safety training to our staff Administrative Staff
Other (please specify)
5
. How frequently do you provide safety training to your staff?
At Orientation
Annually
Every two years
Other
N/A
Professional
*
How frequently do you provide safety training to your staff? Professional At Orientation
Professional Annually
Professional Every two years
Professional Other
Professional N/A
Paraprofessional
Paraprofessional At Orientation
Paraprofessional Annually
Paraprofessional Every two years
Paraprofessional Other
Paraprofessional N/A
Administrative
Administrative At Orientation
Administrative Annually
Administrative Every two years
Administrative Other
Administrative N/A
Other (please specify)
6
. Professional Staff. Please answer the following questions in regard to your professional staff:
Yes
No
Mostly
In some cases
Unsure
Not applicable
Oriented to emergency plan
*
Professional Staff. Please answer the following questions in regard to your professional staff: Oriented to emergency plan Yes
Oriented to emergency plan No
Oriented to emergency plan Mostly
Oriented to emergency plan In some cases
Oriented to emergency plan Unsure
Oriented to emergency plan Not applicable
Aware of potential change in roles
Aware of potential change in roles Yes
Aware of potential change in roles No
Aware of potential change in roles Mostly
Aware of potential change in roles In some cases
Aware of potential change in roles Unsure
Aware of potential change in roles Not applicable
Has plan for self and family
Has plan for self and family Yes
Has plan for self and family No
Has plan for self and family Mostly
Has plan for self and family In some cases
Has plan for self and family Unsure
Has plan for self and family Not applicable
Works with patients towards their own plan
Works with patients towards their own plan Yes
Works with patients towards their own plan No
Works with patients towards their own plan Mostly
Works with patients towards their own plan In some cases
Works with patients towards their own plan Unsure
Works with patients towards their own plan Not applicable
Other (please specify)
7
. Paraprofessional Staff. Please answer the following questions in regard to your paraprofessional staff:
Yes
No
Mostly
In some cases
Not sure
Not Applicable
Oriented to emergency plan
*
Paraprofessional Staff. Please answer the following questions in regard to your paraprofessional staff: Oriented to emergency plan Yes
Oriented to emergency plan No
Oriented to emergency plan Mostly
Oriented to emergency plan In some cases
Oriented to emergency plan Not sure
Oriented to emergency plan Not Applicable
Aware of potential change in roles
Aware of potential change in roles Yes
Aware of potential change in roles No
Aware of potential change in roles Mostly
Aware of potential change in roles In some cases
Aware of potential change in roles Not sure
Aware of potential change in roles Not Applicable
Has plan for self and family
Has plan for self and family Yes
Has plan for self and family No
Has plan for self and family Mostly
Has plan for self and family In some cases
Has plan for self and family Not sure
Has plan for self and family Not Applicable
Works with patients towards their own plan
Works with patients towards their own plan Yes
Works with patients towards their own plan No
Works with patients towards their own plan Mostly
Works with patients towards their own plan In some cases
Works with patients towards their own plan Not sure
Works with patients towards their own plan Not Applicable
Other (please specify)
8
. Please respond to the questions below in regard to your administrative/office staff/non direct care staff.
Yes
No
Mostly
In some cases
Unsure
Not applicable
Oriented to emergency plan
*
Please respond to the questions below in regard to your administrative/office staff/non direct care staff. Oriented to emergency plan Yes
Oriented to emergency plan No
Oriented to emergency plan Mostly
Oriented to emergency plan In some cases
Oriented to emergency plan Unsure
Oriented to emergency plan Not applicable
Aware of potential change in roles
Aware of potential change in roles Yes
Aware of potential change in roles No
Aware of potential change in roles Mostly
Aware of potential change in roles In some cases
Aware of potential change in roles Unsure
Aware of potential change in roles Not applicable
Has plan for self and family
Has plan for self and family Yes
Has plan for self and family No
Has plan for self and family Mostly
Has plan for self and family In some cases
Has plan for self and family Unsure
Has plan for self and family Not applicable
Works with patients towards their own plan
Works with patients towards their own plan Yes
Works with patients towards their own plan No
Works with patients towards their own plan Mostly
Works with patients towards their own plan In some cases
Works with patients towards their own plan Unsure
Works with patients towards their own plan Not applicable
Other (please specify)
9
. What do you consider the most significant barriers in planning (not responding) for emergencies? Answer all that apply.
What do you consider the most significant barriers in planning (not responding) for emergencies? Answer all that apply.
Time
Financial resources
Planning resources
Staff resistance
Community partner resistance
Overall lack of knowledge
Other (please specify)
10
. Is your staff trained in the Incident Command System (ICS)?
Is your staff trained in the Incident Command System (ICS)?
Yes
No
In part
Other (please specify)
11
. Have you, or members of your agency, worked with your local planners to best determine your role in and ability to assist in a community wide disaster?
Have you, or members of your agency, worked with your local planners to best determine your role in and ability to assist in a community wide disaster?
Yes, we are clear in our roles and responsibilities
Yes, but to no concrete conclusion
No
Other (please specify)
12
. How many drills and exercises has your agency conducted or been involved with in the last year?
How many drills and exercises has your agency conducted or been involved with in the last year?
0
1
2
3
4
5 or more
Other (please specify)
13
. Please list any additional comments and concerns here:
Please list any additional comments and concerns here:
Javascript is required for this site to function, please enable.