2018 Disaster Exercise Participation Survey

Extended Power Outage

This year’s training and exercise scenario seeks to prepare your staff for an extended power outage.

Please complete the following survey this information will let the Public Health Department know how your facility/agency will be participating during the exercise. For more information about the exercise please visit the webpage.

If you have any questions about the exercise or this form please contact: phdpreparedness@sbcphd.org or (805) 681-4912.

Question Title

* 1. Contact Information

Name

Facility/Agency

Email Address

Question Title

* 2. Facility/Agency Type: (check all that apply)

Hospital

Skilled Nursing Facility

Intermediate Care Facility

Clinic

Surgery Center

Home Health

RCFE/Assisted Living

Dialysis

Public Health Clinic

Home Health/Hospice Agency

Other (please specify)

Question Title

* 3. Will your facility/agency be participating in the November 13-15th Exercise?

Yes, my facility/agency will be participating in the November 13-15th Exercise.

No, my facility/agency will NOT be participating in the November 13-15th Exercise.

Question Title

* 4. Does your facility/agency plan to conduct a tabletop prior to the November 13th-15th exercise?

Yes! My facility/agency will conduct a tabletop exercise prior to the exercise

No! My facility/agency does not plan to conduct a tabletop prior to the exercise

Question Title

* 5. How will your facility/agency participate in the November 13th-15th Exercise
Please check all that apply to your facility/agency.

Minimum participation: Respond to all CAHAN Alerts, Submit Status Report

Conduct and tabletop drill at your facility/agency.

Conduct a full scale exercise at your facility/agency. (evacuation, accounting for staff, COOP, generator failure etc.)

Other (please specify)

Question Title

* 6. What to you plan to test during your facility's full scale exercise? (check all that apply)

Activate Emergency Operations Plan

Activate command structure (ICS, HICS, NHICS etc.)

Set up and run command center for facility/agency

Surge of patients from community

Run on generator power

Generator failure

Movement of vaccines or medication

Paper charting or records

Facility evacuation

Communication with staff

Other (please specify)

2018 Disaster Exercise Participation Survey

Extended Power Outage

Question Title

* 1. Contact Information

Question Title

* 2. Facility/Agency Type: (check all that apply)

Question Title

* 3. Will your facility/agency be participating in the November 13-15th Exercise?

Question Title

* 4. Does your facility/agency plan to conduct a tabletop prior to the November 13th-15th exercise?

Question Title

* 5. How will your facility/agency participate in the November 13th-15th Exercise
Please check all that apply to your facility/agency.

Question Title

* 6. What to you plan to test during your facility's full scale exercise? (check all that apply)

Question Title

* 7. Please provide any other information on your facility's full scale exercise below:

Question Title

* 8. Comments or Questions?
Please include any questions you have about the exercise below.

Question Title

* 1. Contact Information

Question Title

* 2. Facility/Agency Type: (check all that apply)

Question Title

* 3. Will your facility/agency be participating in the November 13-15th Exercise?

Question Title

* 4. Does your facility/agency plan to conduct a tabletop prior to the November 13th-15th exercise?

Question Title

* 5. How will your facility/agency participate in the November 13th-15th Exercise Please check all that apply to your facility/agency.

Question Title

* 6. What to you plan to test during your facility's full scale exercise? (check all that apply)

Question Title

* 7. Please provide any other information on your facility's full scale exercise below:

Question Title

* 8. Comments or Questions? Please include any questions you have about the exercise below.

* 5. How will your facility/agency participate in the November 13th-15th Exercise
Please check all that apply to your facility/agency.

* 8. Comments or Questions?
Please include any questions you have about the exercise below.