This survey has been developed by the Healthcare Coalition of Rhode Island (HCRI) to reflect the Kaiser Permanente HVA Tool (2021 ed.). 

It is recommended that your organization first complete the Kaiser-Permanente HVA (above), and then report results from it into this survey. HCRI encourages a collaborative approach; a discussion guided by the HVA tool among key members of your organization/agency/facility can help identify potential gaps in preparedness that could be mitigated. 

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* 1. Contact Information

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* 2. Organization Type

(Please select from below)

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* 3. Please score the expected PROBABILITY of each threat/hazard:

Likelihood threat or hazard will occur.

0 = N/A
1 = Low
2 = Moderate
3 = High

  Likelihood of Occurrence
Active Shooter
Act of Terrorism
Air Quality Issue
Bomb Threat
Building Move
Chemical Exposure, External
Chemical Exposure, Internal
Chemical Spill
Child Abduction
Civil Unrest / Protesting
Communication / Telephony Failure
Dam Failure
Drought
Earthquake
Epidemic
Evacuation
Explosion
Fire Alarm Failure
Fire, External
Fire, Internal
Flood, External
Flood, Internal
Forensic Admission
Gas / Emissions Leak
Generator Failure
Hostage Situation
Hurricane
HVAC Failure
Inclement Weather
Infectious Disease Outbreak
IT System Outage
Landslide
Mass Casualty Incident - Hazmat
Mass Casualty Incident - Medical
Mass Casualty Incident - Trauma
Medical Gas Disruption
Natural Gas Disruption
Pandemic
Patient Elopement
Patient Surge
Picketing
Planned Power Outage
Power Outage
Radiation Exposure
Seasonal Influenza
Sewage Failure
Shelter in Place
Staff Burnout / Attrition
Strikes / Labor Action / Work Stoppage
Suicide
Supply Chain Shortage / Failure
Suspicious Package / Substance
Temperature Extremes
Tornado
Transportation Failure (e.g., bridge closure, rail strike)
Trauma
Tsunami
Utility Failure
VIP Situation
Water Contamination
Water Disruption
Weapon
Workplace Violence / Threat

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* 4. Please score the expected IMPACT of each threat/hazard:

Possibility of death or injury, physical losses and damages, and/or interruption of services.

0 = N/A
1 = Low
2 = Moderate
3 = High

  Human Impact (Casualties, fatalities) Property Impact (Building, structure damage) Business Impact (Interruption of services)
Active Shooter
Act of Terrorism
Air Quality Issue
Bomb Threat
Building Move
Chemical Exposure, External
Chemical Exposure, Internal
Chemical Spill
Child Abduction
Civil Unrest / Protesting
Communication / Telephony Failure
Dam Failure
Drought
Earthquake
Epidemic
Evacuation
Explosion
Fire Alarm Failure
Fire, External
Fire, Internal
Flood, External
Flood, Internal
Forensic Admission
Gas / Emissions Leak
Generator Failure
Hostage Situation
Hurricane
HVAC Failure
Inclement Weather
Infectious Disease Outbreak
IT System Outage
Landslide
Mass Casualty Incident - Hazmat
Mass Casualty Incident - Medical
Mass Casualty Incident - Trauma
Medical Gas Disruption
Natural Gas Disruption
Pandemic
Patient Elopement
Patient Surge
Picketing
Planned Power Outage
Power Outage
Radiation Exposure
Seasonal Influenza
Sewage Failure
Shelter in Place
Staff Burnout / Attrition
Strikes / Labor Action / Work Stoppage
Suicide
Supply Chain Shortage / Failure
Suspicious Package / Substance
Temperature Extremes
Tornado
Transportation Failure (e.g., bridge closure, rail strike)
Trauma
Tsunami
Utility Failure
VIP Situation
Water Contamination
Water Disruption
Weapon
Workplace Violence / Threat

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* 5. Please score your organization's MITIGATION against each threat/hazard:

Planning and preparations, speed of response and available resources, and/or community and mutual aid support.

0 = N/A
1 = Low
2 = Moderate
3 = High

  Preparedness Internal Response (Time, effectiveness, resources) External Response (Community, mutual aid resources)
Active Shooter
Act of Terrorism
Air Quality Issue
Bomb Threat
Building Move
Chemical Exposure, External
Chemical Exposure, Internal
Chemical Spill
Child Abduction
Civil Unrest / Protesting
Communication / Telephony Failure
Dam Failure
Drought
Earthquake
Epidemic
Evacuation
Explosion
Fire Alarm Failure
Fire, External
Fire, Internal
Flood, External
Flood, Internal
Forensic Admission
Gas / Emissions Leak
Generator Failure
Hostage Situation
Hurricane
HVAC Failure
Inclement Weather
Infectious Disease Outbreak
IT System Outage
Landslide
Mass Casualty Incident - Hazmat
Mass Casualty Incident - Medical
Mass Casualty Incident - Trauma
Medical Gas Disruption
Natural Gas Disruption
Pandemic
Patient Elopement
Patient Surge
Picketing
Planned Power Outage
Power Outage
Radiation Exposure
Seasonal Influenza
Sewage Failure
Shelter in Place
Staff Burnout / Attrition
Strikes / Labor Action / Work Stoppage
Suicide
Supply Chain Shortage / Failure
Suspicious Package / Substance
Temperature Extremes
Tornado
Transportation Failure (e.g., bridge closure, rail strike)
Trauma
Tsunami
Utility Failure
VIP Situation
Water Contamination
Water Disruption
Weapon
Workplace Violence / Threat

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* 6. Please identify any additional threats/hazards posed to your organization/agency/facility not reflected above.

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