Hospital Emergency Department Director's Survey
Preparedness for WIPP Transportation Incidents
6/99

Hospital Name: _________________________________

County: _____________________________________

Date: __________ Name: __________________________Phone: ________________

ED Fax: ______________

Address: _________________________________________

City:_____________________ Zip: ____________

About your facility:

1.Please list the total number of medical personnel in your emergency department:

Emergency Physicians (M.D., D.O.) ________
Physician's Assistant________
Registered Nurse________
Licensed Practical Nurse________
EMT________
Respiratory Therapist________
Radiation Safety Officer________
Radiology Tech________
ER Tech________
Other________
TOTAL NUMBER ________

2.List the ambulance services / fire departments that routinely transport patients to your hospital:

____________________________________________________________ _____

____________________________________________________________ _____

About your employees:

3.Have your employees received training on response to a WIPP transportation incident?
___Yes ___No

4.If yes, please list the course title(s), number of personnel trained and approximate dates:

____________________________________________________________ ______

____________________________________________________________ ______

____________________________________________________________ ______

5.Have your employees received training on treating radioactively contaminated patients? ___Yes ___ No

6.If yes, please list the course title(s), number of personnel trained and approximate dates:

____________________________________________________________ ______

____________________________________________________________ ______

____________________________________________________________ ______

7.What percentage of your employees received this training? __________

8.Did your facility participate in a drill or an exercise as part of the training?
___ Yes ___ No

9.Does your hospital have a designated room / area for decontamination of haz mat / radiation contaminated patients? ___ Yes ___ No

10.Do you think that your hospital staff could safely respond to a WIPP transportation incident? ___ Yes ___ No

11.If no, what do you and your staff need and/or recommend in order to achieve and maintain proficiency for response to a WIPP transportation incident (e.g., more training, equipment, policy/procedures). Please be specific.

____________________________________________________________ ______

____________________________________________________________ ______

12.Have you received training in the use of the DTPA medication? ___ Yes ___ No

13.Where is your DTPA medication located?

_____________________________________

14.Did you know that the State of New Mexico sponsors WIPP training and WIPP transportation incident exercises at no cost? ___ Yes ___No

15.Does your hospital / department have a Standard Operating Guide or Policy for your employees to follow for response to hazardous materials incidents? ___Yes ___ No

16.Who is responsible for cleaning or replacing your department's contaminated equipment?

____________________________________________________________ ______

17.Do you wish to receive notification of WIPP shipments? ___ Yes ___ No

18.If yes, how do you want to receive that information?
___ local media ___ telephone call or fax to hospital emergency department

About your community:

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

20.If yes, do you know your hospital's responsibility in the plan? ____ Yes ___ No

21.Additional comments (use additional pages if needed):

____________________________________________________________ _______

____________________________________________________________ _______

____________________________________________________________ _______

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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