Emergency Medical Services Responder
Survey

Date: ________ Service Name: ______________________ County: _______________

About you:
Your Name: (optional) __________________________________

1.Your training level (check all that apply): ___Dispatcher ___Medical 1^st Responder ___EMT-B ___EMT-I ___ EMT-P ___ RN ___Firefighter ___ Law Enforcement

Job Title: ________________________________________________________

2.For your job relevant to this survey are you: ___ Volunteer ___ Paid (If paid, are you a union member? ___ Yes ___ No)

3.Whether paid or volunteer, do you receive hazard pay or other benefits for response to radiation/hazardous materials incidents?
___ Yes ___No

4.Have you attended training that included information about the WIPP transportation program?
___ Yes ___ No

5.Did you know that the State of New Mexico sponsors free WIPP training?
___ Yes ___ No

6.Have you attended training that included information about the medical treatment of WIPP accident victims?
___ Yes ___ No

List the course(s) titles and approximate date(s) that you attended:

______________________________________________________________________

______________________________________________________________________

7.Did you participate in a drill or exercise as a part of the training?
___ Yes ___ No

8.Do you feel adequately trained to safely handle a radioactively contaminated patient?
___ Yes ___ No

9.If no, what do you think you need to feel adequately trained to handle a radioactively contaminated patient? ____ More training ____ Equipment ____ Written Policies/Procedures
Comments:

_____________________________________________________________________< P> _____________________________________________________________________< BR>

10.What highest level of Hazardous Materials Training / Response have you been trained to (according to OSHA 29 CFR 1910.120)?
___ Awareness ___ Operations ____ Technician ___ Specialist ____ On Scene Command

11.To what level of response are you expected to perform at a hazardous materials incident?
___ Awareness ___ Operations ____ Technician ___ Specialist ____ On Scene Command

12.Do you think that you can safely perform those skills checked in the previous question?
___ Yes ___ No

13.Do you want to know the schedule of WIPP shipments? ___ Yes ___ No

14.Will you personally respond to a radioactive materials incident? ___ Yes ___ No

15.Will you personally respond to a hazardous materials incident? ___ Yes ___ No

16.Who do you think is responsible for cleaning / replacing your personal equipment taken to the scene of a radioactive/hazardous materials incident?

_____________________________________________________________________< BR>

About your agency/department:

17.Does your department/agency carry workers compensation and/or injury insurance for you as a responder?
___ Yes ___ No

18.Do you think that your department/agency has the equipment (including radiation detection equipment) that it needs to perform the skills necessary for radioactive / hazardous materials response?
___ Yes ___ No

19.If no, what do you think your department needs for response to a WIPP transportation incident? Please be specific (e.g., policy/procedure, equipment, training):

____________________________________________________________________

____________________________________________________________________

20.If yes, do you have access to radiation detection equipment? ___ Yes ___ NO

21.Who do you think is responsible for cleaning or replacing contaminated department/agency equipment?

_____________________________________________________________________< BR>

About your community: 22.Does your community have an all hazards plan? ___ Yes ___ No ___ Don't know

23.If yes, do you understand your role as a responder in that plan? ____ Yes ___ No

24.Comments (use additional pages if needed):

_____________________________________________________________________< P> _____________________________________________________________________< P> _____________________________________________________________________< BR>

Please return this survey to:
Ralph Davis
WIPP Medical Preparedness Coordinator
Injury Prevention and EMS Bureau, New Mexico Dept. of Health
P.O. Box 26110
Santa Fe, New Mexico 87502

Telephone: 505-476-7000 ex. 123
Fax: 505-476-7010
Email: ralphd@doh.state.nm.us

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