Hospital Emergency Department Staff
Survey
Preparedness for WIPP Transportation Incidents
6/99
Date: ________ Hospital Name: _____________________________
County: __________________
About You:
(Optional) Your Name:
_________________________________
Check your training / staff level (check all that apply):
___ Emergency Room Physician;
___ Emergency Department Staff; ___ PA; ___ RN;
___LPN; ___ ER Tech;
___ Respiratory Therapist; ___ EMT; ___ Radiology Tech; ___
Radiation Safety Officer
___ Other - please describe_______________
Job Title:
___________________________________________________
About Your Training:
1.Have you attended training
that included information about WIPP transportation?
___ Yes ___ No
2.Did you know that the
State of New Mexico sponsors WIPP medical response training
at no cost? ___ Yes ___ No
3.Have you attended training
that included information about the medical treatment of
WIPP accident victims? ___ Yes ___ No
4.If yes, please list the
course title(s) and approximate date(s) that you
attended:
____________________________________________________________
__
____________________________________________________________
__
5.Did you participate in a
drill or exercise as a part of the training? ___ Yes ___
No
6.Do you understand your
role in a hazardous materials incident? ___ Yes ___
No
7.Do you feel adequately
trained to safely handle a radioactively contaminated
patient?
___ Yes ___ No
8.If no, what do you think
you need to feel adequately trained to handle a
radioactively contaminated patient? ____ more training
____ equipment ____ policy/procedure
Please list specific needs:
____________________________________________________________
___
____________________________________________________________
___
9.Do you want to know the
schedule of WIPP shipments? ___ Yes ___ No
10.If yes, how do you want
to receive that information?
___ local media; ___ telephone call or fax to hospital
emergency department
11.Would you personally
respond to a radioactive materials incident? ___ Yes ___
No
12.Would you personally
respond to a hazardous materials incident? ___ Yes ___ No
About your hospital:
13.Do you think that your
department/agency has the equipment (including radiation
detection equipment) it needs to perform the skills
necessary for radioactive / hazardous materials response?
___ Yes ___ No
14.If no, please list the
equipment that you think your department or agency needs to
respond to a radioactive / hazardous materials incident (be
specific).
____________________________________________________________
___
____________________________________________________________
___
15.If you answered yes, can
you access the radiation detection equipment? ___ Yes ___
No
16.Who do you think is
responsible for cleaning or replacing contaminated
department / agency equipment?
____________________________________________________________
___
17.Who do you think is
responsible for cleaning / replacing personal equipment that
may become contaminated responding to a radioactive /
hazardous materials incident?
____________________________________________________________
___
About Your Community:
18.Does your community have
an all hazards plan? ___ Yes ___ No ___ Don't Know
19.If yes, do you understand
your role in the all hazards plan? ____ Yes ___ No
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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