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Methodist Hospital

Physician Services Emergency Preparedness Program Form

Associated Event: Please select "No Event Selected" from the drop down box below.
Associated Event   
* Location
  Type of program Simulation     Activation    
  Date of Activation
  Site/Department Reporting
  Time initiated/announced
  Number of participants
  Describe evacuation of patients/visitors/staff to safe site/location
  Other actions taken
  Time of all clear
  Were all patients/visitors & staff members accounted for at the evacuation site? YES     NO    
  Where all involved staff members familiar with codes, routes, procedures, etc? YES     NO    
  Was evacuation conducted in a safe manner through halls, down stairs, etc? YES     NO    
  Office searched for patients, visitors, and/or staff in preparation for evacuation? YES     NO    
  Able to state designated safe site/gathering evacuation spot? YES     NO    
  Was the overall evacuation conducted in a manner indicating thorough knowledge of procedures by all personnel involved? YES     NO    
  Comments:
  Evaluated By :