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1 |
[record_id] |
Record ID |
text |
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2 |
[consent] |
Section Header: SECTION A: INFORMED CONSENT & ETHICAL COMPLIANCE
Informed Consent Form
Study Title: Leveraging the Health Disaster Resilience Assessment (HDRA) and Monitoring Framework Tools for Strengthening Health Facility Resilience: A Case-Control Study
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descriptive |
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3 |
[id] |
Study Number |
text, Required |
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4 |
[healthcare_fac_name] |
Name of Healthcare Facility |
text, Required |
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5 |
[fac_address] |
Address of Facility |
notes, Required |
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6 |
[fac_head] |
Head of Institution Name & Designation |
notes |
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7 |
[consent_date] |
Consent Statement
1. I confirm that I have read and understood the information sheet dated _________________ for the above study and have had the opportunity to ask questions.
2. I understand that my participation in this study is voluntary and that I am free to withdraw at any time, without giving any reason and without affecting my facility's relationships with any public or private organizations.
3. I understand that the Ethics Committee and regulatory authorities may review facility records relating to this study and any future research without requiring my permission, although my facility's identity will not be revealed in any published information.
4. I agree not to restrict the use of any data or results arising from this study, provided such use is only for scientific purposes and does not compromise facility confidentiality.
5. I agree to participate in this combined assessment tool (questionnaire and scoring) and provide voluntary consent for my facility's participation.
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text (date_dmy), Required, Identifier |
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8 |
[fac_representative] |
Facility Representative |
file (signature) |
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9 |
[sign_date] |
Date |
text (date_dmy), Required, Identifier |
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10 |
[reprsentative_name] |
Name and Designation |
text, Required |
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11 |
[investigator_sign] |
PI/Investigator Signature |
file (signature), Required, Identifier |
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12 |
[date] |
Date |
text (date_dmy), Required, Identifier |
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13 |
[investigator_name] |
Investigator Name |
text |
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14 |
[witness_sign] |
Witness Signature |
file (signature) |
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15 |
[witness_date] |
Date |
text (date_dmy) |
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16 |
[witness_name] |
Witness Name |
text |
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17 |
[fac_name] |
Section Header: SECTION B: FACILITY DEMOGRAPHICS & GENERAL INFORMATION
Facility name
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text, Required |
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18 |
[fac_type] |
Facility Type |
radio| 1 | Hospital | | 2 | Primary Health Center | | 3 | Community Health Center | | 4 | Other |
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19 |
[if_other_fac_type]
Show the field ONLY if:
[fac_type] = '4'
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If other |
text |
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20 |
[fac_add] |
Address (Full) |
text, Required |
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21 |
[fac_location] |
City/District/State |
notes, Required |
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22 |
[fac_contact] |
Contact Number |
text |
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23 |
[date_assessment] |
Date |
text (date_dmy), Required, Identifier |
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24 |
[fac_contact_detail] |
Email and Website |
text (email) |
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25 |
[fac_est_year] |
Establishment Year |
text |
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26 |
[fac_accreditation] |
NABH/NRHM/Other Accreditation |
radio, Required, Identifier |
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27 |
[fac_recognised_by] |
Accreditation Body |
text |
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28 |
[fac_item] |
Total Number of Beds |
text, Required |
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29 |
[fac_occupancy] |
Hospital Occupancy Rate |
text, Required, Identifier |
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30 |
[fac_services] |
Departments/Services operational |
checkbox, Identifier| 1 | fac_services___1 | General Medicine | | 2 | fac_services___2 | Surgery | | 3 | fac_services___3 | Pediatrics | | 4 | fac_services___4 | ICU | | 5 | fac_services___5 | Emergency | | 6 | fac_services___6 | Other(specify): | | 7 | fac_services___7 | xxx |
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31 |
[key_person] |
Key Personals Present (Name & Designation) |
notes |
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32 |
[fac_discription] |
Facility Description |
notes |
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33 |
[decriptive] |
Section Header: SECTION C: HAZARD PROFILE & VULNERABILITY ASSESSMENT
Assessment Instructions
Rate the facility's exposure to and experience with each hazard using the scale: 1 = Very High/Severe, 2 = High, 3 = Moderate, 4 = Low, 5 = Not Severe/Not Frequent
Refer to hazard maps (available from district authorities), past event records, and facility disaster history when scoring. Document observations (e.g., "2019 earthquake 5.2M caused minor crack in east wall").
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descriptive |
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34 |
[geo_hazard] |
C.1 Geological Hazards |
dropdown |
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35 |
[earthquakes] |
Section Header: Geological Hazard
Earthquakes
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checkbox| 1 | earthquakes___1 | Very Severe | | 2 | earthquakes___2 | High | | 3 | earthquakes___3 | Moderate | | 4 | earthquakes___4 | Low | | 5 | earthquakes___5 | Not Severe |
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36 |
[landslides] |
Land Slides |
checkbox| 1 | landslides___1 | Very Severe | | 2 | landslides___2 | High | | 3 | landslides___3 | Moderate | | 4 | landslides___4 | Low | | 5 | landslides___5 | Not Severe |
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37 |
[other] |
Other |
checkbox| 1 | other___1 | Very Severe | | 2 | other___2 | High | | 3 | other___3 | Moderate | | 4 | other___4 | Low | | 5 | other___5 | Not Severe |
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38 |
[geo_hazard_other]
Show the field ONLY if:
[other(5)] = '1'
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if Other |
text |
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39 |
[earthquake] |
Section Header: Geo_Frequency
Earthquakes
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radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
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40 |
[landslide] |
Land Slides |
radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
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41 |
[othes] |
Other |
radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
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42 |
[observation] |
Observations (e.g., past events, distance to epicenter)
Details:
Recent tremors
Proximity to unstable slopes
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descriptive |
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43 |
[earthquake_observation] |
Earthquake |
text |
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44 |
[land_slide_observation] |
Land Slide |
text |
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45 |
[other_observation] |
Other |
text |
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46 |
[floods] |
Section Header: C.2 Hydro-Meteorological Hazards
Floods (Riverine/Urban)
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radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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47 |
[rainfall] |
Heavy Rainfall/Storm Surge |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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48 |
[erosion] |
River Erosion |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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49 |
[heatwave] |
Heat Wave |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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50 |
[cyclone] |
Cyclone/Storm |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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51 |
[hydro_other] |
Other |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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52 |
[hydro_others] |
If Hydro Other |
text |
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53 |
[flood_frequency] |
Section Header: Hydro_Hazard_Frequency
Floods (Riverine/Urban)
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radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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54 |
[rainfall_frequency] |
Heavy Rainfall/Storm Surge |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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55 |
[erosion_frequency] |
River Erosion |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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56 |
[heatwave_frequency] |
Heat Wave |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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57 |
[cyclone_frequency] |
Cyclone/Storm |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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58 |
[other_frequency] |
Other |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
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59 |
[flood] |
Last Flood |
text (date_dmy), Required |
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60 |
[flood_duration] |
Inundation depth/duration |
text |
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61 |
[river_dist] |
Distance to river |
text |
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62 |
[river_risk] |
Erosion Risk |
yesno |
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63 |
[heat_wave] |
Heat Wave Duration |
text |
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64 |
[cyclone_freq] |
Cyclone Seasonal occurrence |
yesno |
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65 |
[epidemeological_risk] |
Section Header: C.3 Environmental & Biological Hazards
Epidemic/Pandemic Risk
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radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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66 |
[vector_disease] |
Vector-Borne Diseases (malaria, dengue, Japanese Encephalitis, etc.) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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67 |
[water_con] |
Water Contamination |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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68 |
[air_pollu] |
Air Pollution |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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69 |
[animal_incident] |
Snake/Animal Bite Incidents |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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70 |
[other_envior_hazard] |
Other (specify) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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71 |
[risk_type] |
Type of Risk |
dropdown (autocomplete) |
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72 |
[affected_risk] |
Affected |
dropdown (autocomplete) |
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73 |
[vector_name] |
Endemic Species |
text |
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74 |
[water_contamination] |
Water Contamination Source |
text |
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75 |
[air_sources] |
Air Pollution Sources |
text |
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76 |
[bite_frequency] |
Animal Bites frequency |
text |
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77 |
[industrial_hazard] |
Section Header: C.4 Technological & Chemical Hazards
Industrial Accidents/Spills
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radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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78 |
[transportational_hazard] |
Hazardous Material Transportation |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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79 |
[fire_hazard] |
Fire Risk (external) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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80 |
[explosive_hazard] |
Explosions |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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81 |
[other_chemical] |
Other (specify) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
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82 |
[other_industrial] |
if Other Industrial Hazard |
text |
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83 |
[dist_industry] |
Proximity to refineries\industries (in KM) |
text |
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84 |
[facility_route] |
Routes to Facility |
dropdown |
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85 |
[nearby_surrounding] |
Surrounding Structures |
dropdown |
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86 |
[dist_site] |
Proximity to Hazardous site (in Km) |
text |
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87 |
[civil_unrest] |
Section Header: C.5 Social & Anthropogenic Hazards
Civil Unrests\ Armed Conflict
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radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
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88 |
[displacement] |
Displaced Population |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
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89 |
[mass_gathering] |
Mass Gatherings |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
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90 |
[social_other] |
Others |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
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91 |
[other_anthropogenic] |
if Other Anthropogenic Hazard |
text |
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92 |
[civil_conflicts] |
History of Civil unrest |
dropdown |
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93 |
[facility_impact] |
Displacement cause Impact on Facility |
dropdown |
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94 |
[mass_gathering_proximity] |
Proximity of Gathering (in Km) |
text |
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95 |
[maa_gathering_frequency] |
Frequency of Gathering |
radio| 1 | Frequent | | 2 | Occasional | | 3 | Once a while |
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96 |
[village_distance] |
Section Header: C.6 Surrounding Environment & Infrastructure Proximity
Village/Settlement (in KM)
|
text |
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97 |
[village_density]
Show the field ONLY if:
[village_distance] = ''
|
Population density |
text |
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98 |
[shelter_proximity] |
School/Community Center (shelter potential) (in KM) |
text |
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99 |
[shelter_capacity]
Show the field ONLY if:
[shelter_proximity] = ''
|
Capacity |
text |
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100 |
[civil_service_office] |
Police/Fire Station (in Km) |
text |
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101 |
[service_response_time]
Show the field ONLY if:
[civil_service_office] = ''
|
Response time |
text |
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102 |
[mode_transportation] |
Major Transportation Hub (in Km) |
text |
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103 |
[transportation_mode]
Show the field ONLY if:
[mode_transportation] = ''
|
Mode |
text |
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104 |
[hazardous_site] |
Hazardous Facility (landfill/refinery/factory) (in Km) |
text |
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105 |
[hazard_risk]
Show the field ONLY if:
[hazardous_site] = ''
|
Type/risk |
text |
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106 |
[dist_flood_prone] |
River/Water Body (in Km) |
text |
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107 |
[flood_risk]
Show the field ONLY if:
[dist_flood_prone] = ''
|
Risk of flooding |
dropdown |
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108 |
[range] |
Rate the facility's proximity to key infrastructure (1 = >15 km, 2 = 15km to 10 km, 3 = 10km to 5 km, 4= 5km to 1km 5 = < 1 km) or hazardous sites (1 = >15 km, 2 = 15km to 10 km, 3 = 10km to 5 km, 4= 5km to 1km 5 = < 1 km) ): |
descriptive |
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109 |
[village] |
Section Header: Proximity\ Hazardous Site
Village/ settlement
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radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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110 |
[shelter] |
School/Community Center (shelter potential) |
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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111 |
[service] |
Police/Fire Station |
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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112 |
[transportation] |
Major Transportation Hub |
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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113 |
[hazardous] |
Hazardous Facility (landfill/refinery/factory) |
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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114 |
[floodzone] |
River/Water Body |
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
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115 |
[building_characterstics] |
Section Header: SECTION D: PHYSICAL INFRASTRUCTURE & BUILDING SAFETY
Building Characteristics
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descriptive |
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116 |
[construction_year] |
Year of Construction |
text |
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117 |
[structure_assessment] |
Structural assessment |
text |
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118 |
[maintenance_structure] |
Last Maintenance |
text (date_dmy), Required |
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119 |
[damage_type] |
Type of Damage |
text |
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120 |
[repair_duration] |
Duration of Repair |
text |
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121 |
[age] |
Section Header: building_score
Age of Building
|
radio (Matrix - ranking) |
|
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122 |
[quality] |
Construction Quality |
radio (Matrix - ranking) |
|
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123 |
[maintainence] |
Maintenance & Retrofitting |
radio (Matrix - ranking) |
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124 |
[past_damage] |
Past Damage from Disasters |
radio (Matrix - ranking) |
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125 |
[post_repair] |
Post-Disaster Repair |
radio (Matrix - ranking) |
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126 |
[score_classification] |
1=>50 years; 2=40-50 yrs; 3=20-40 yrs; 4=10-20 yrs; 5=< 10 yrs
1=Thatch; 2=CI sheet; 3=Mix; 4=Confined masonry; 5=RCC
1=Never; 2=Once in 2 yrs; 3=Annually; 4=6-monthly; 5=Quarterly
1=Complete; 2=Severe; 3=Moderate; 4=Slight; 5=None
1=Not repaired; 2=Poor; 3=Moderate; 4=Good; 5=Best
|
descriptive |
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127 |
[evacuation_safety] |
D.2 Evacuation & Safety Routes |
descriptive |
|
|
128 |
[routes] |
Evacuation Routes |
radio (Matrix - ranking) |
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129 |
[assemble] |
Evacuation Assembly Points |
radio (Matrix - ranking) |
|
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130 |
[signage] |
Exit Signage & Lighting |
radio (Matrix - ranking) |
|
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131 |
[triage] |
Triage/Decontamination Areas |
radio (Matrix - ranking) |
|
|
132 |
[indicators] |
Indicator
1=Absent; 2=Not marked; 3=Incorrectly marked; 4=Partially marked; 5=Clearly demarcated
1=None; 2=Identified; 3=Partially marked; 4=Marked; 5=Marked & sheltered
1=None; 2=Poor; 3=Moderate; 4=Good; 5=Comprehensive
1=Not designated; 2=Inadequate; 3=Adequate; 4=Well-designed; 5=Multi-purpose & functional
|
descriptive |
|
|
133 |
[emergency_exit] |
Number of exits |
text |
|
|
134 |
[assembly_capacity] |
Capacity (in Numbers) |
text |
|
|
135 |
[emergcy_lights] |
Emergency Lightning |
dropdown |
|
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136 |
[lift] |
Lift |
dropdown |
|
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137 |
[ramp] |
Ramp |
dropdown |
|
|
138 |
[tactile_path] |
Tactile Path |
dropdown |
|
|
139 |
[location_triage] |
Location |
text |
|
|
140 |
[hospital_capacity] |
D.3 Hospital Capacity & Surge Capacity |
descriptive |
|
|
141 |
[gen_bed] |
Section Header: General Medicine
Number of Beds
|
text |
|
|
142 |
[gen_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
143 |
[gen_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
144 |
[surg_bed] |
Section Header: Surgery
Normal Beds
|
text |
|
|
145 |
[surg_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
146 |
[surg_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
147 |
[pedia_beds] |
Section Header: Pediatrics
Normal Beds
|
text |
|
|
148 |
[pedia_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
149 |
[pedia_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
150 |
[icu_beds] |
Section Header: ICU/HDU
Normal Beds
|
text |
|
|
151 |
[icu_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
152 |
[icu_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
153 |
[emergency_beds] |
Section Header: Emergency
Normal Beds
|
text |
|
|
154 |
[emergency_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
155 |
[emergency_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
156 |
[ot_beds] |
Section Header: Operating Theater
Normal Beds
|
text |
|
|
157 |
[ot_expansion] |
Expansion Capacity (beds/areas |
text |
|
|
158 |
[ot_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
159 |
[isolation_bed] |
Section Header: Isolation/Quarantine
Normal Beds
|
text |
|
|
160 |
[isolation_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
161 |
[isolation_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
162 |
[others_capacity] |
Other (specify) |
text |
|
|
163 |
[other_beds] |
Normal Beds |
text |
|
|
164 |
[other_expansion] |
Expansion Capacity (beds/areas) |
text |
|
|
165 |
[other_infra] |
Infrastructure for Surge (water, power, comms) |
text |
|
|
166 |
[surge_capacity] |
Hospital and surge capacity |
descriptive |
|
|
167 |
[emergency_space] |
Section Header: Additional Spaces for Emergency Use
(e.g., conference room, gymnasium, abandoned ward)
|
descriptive |
|
|
168 |
[emer_spaces] |
Space 1 |
text |
|
|
169 |
[emer_utilitity] |
Utilities (Water/Power/Phone) |
checkbox| 1 | emer_utilitity___1 | Water | | 2 | emer_utilitity___2 | Power | | 3 | emer_utilitity___3 | Phone |
|
|
|
170 |
[space] |
Space 1 |
radio (Matrix) |
|
|
171 |
[emer_area] |
Area (m²) |
text |
|
|
172 |
[emer_spaces2] |
Space 2 |
text |
|
|
173 |
[emer_utility] |
Utilities |
checkbox| 1 | emer_utility___1 | Water | | 2 | emer_utility___2 | Power | | 3 | emer_utility___3 | Phone |
|
|
|
174 |
[space2] |
Space 2 |
radio (Matrix) |
|
|
175 |
[emer_area2] |
Area (m²) 2 |
text |
|
|
176 |
[fac_ins_main] |
Section Header: SECTION E: FACILITIES, EQUIPMENT & CRITICAL SYSTEMS
E.1 Facility Inspection & Maintenance
|
descriptive |
|
|
177 |
[ins_fre] |
Facility Inspection Frequency |
radio (Matrix - ranking) |
|
|
178 |
[main_sche] |
Equipment Maintenance Schedule |
radio (Matrix - ranking) |
|
|
179 |
[system_test] |
Critical System Testing |
radio (Matrix - ranking) |
|
|
180 |
[ins_option] |
Facility Inspection Frequency: 1=Never; 2=Annually; 3=6-monthly; 4=Quarterly; 5=Monthly
Equipment Maintenance Schedule: 1=Ad-hoc; 2=Annual; 3=6-monthly; 4=Quarterly; 5=Monthly
Critical System Testing: 1=Not done; 2=Annual; 3=Biannual; 4=Quarterly; 5=Monthly
|
descriptive |
|
|
181 |
[ins_date] |
Last Inspection |
text (date_dmy) |
|
|
182 |
[ins_main] |
Maintence record |
dropdown |
|
|
183 |
[ins_test] |
System Test |
checkbox| 1 | ins_test___1 | Water | | 2 | ins_test___2 | Fuel | | 3 | ins_test___3 | Comms |
|
|
|
184 |
[emer_water] |
Section Header: E.2 Emergency Supplies & Resources (72-Hour Requirement)
Water
|
radio (Matrix) |
|
|
185 |
[emer_fuel] |
Fuel/ Diseal |
radio (Matrix) |
|
|
186 |
[emer_elec] |
Electricity |
radio (Matrix) |
|
|
187 |
[emer_gas] |
Medical Gases (O2, Vaccum) |
radio (Matrix) |
|
|
188 |
[emer_med] |
Essential medicine |
radio (Matrix) |
|
|
189 |
[emer_food] |
Food and Nutrition |
radio (Matrix) |
|
|
190 |
[emer_equip] |
Medical Equipment |
radio (Matrix) |
|
|
191 |
[emer_ambulance] |
Ambulances |
radio (Matrix) |
|
|
192 |
[emer_communication] |
Communication equipment |
radio (Matrix) |
|
|
193 |
[emer_fire_equip] |
Fire Safety Equipment |
radio (Matrix) |
|
|
194 |
[emer_res] |
Rate availability of 72-hour emergency supplies in the facility (1=Not available, 2= Critically low, 3= limited, 4= Adequate, 5=Available & fully stocked): |
descriptive |
|
|
195 |
[emer_water_quan] |
Section Header: Water
Quantity (L)
|
text |
|
|
196 |
[water_expire] |
Expiry management |
dropdown |
|
|
197 |
[water_location] |
Location |
text |
|
|
198 |
[fuel_quantity] |
Section Header: Fuel/Diesel (liters)
Quantity(L)
|
text |
|
|
199 |
[fuel_expire] |
Expiry management |
dropdown |
|
|
200 |
[fuel_generator] |
Backup Generator functional |
dropdown |
|
|
201 |
[elec_gener] |
Section Header: Electricity (Generator)
Generator Electric Building Capacity (kW)
|
text |
|
|
202 |
[gene_fuel] |
Fuel Duration in Hrs |
text |
|
|
203 |
[gene_main] |
Maintenance |
dropdown |
|
|
204 |
[emer_gas_dur] |
Section Header: Medical Gases (O₂, Vacuum)
Duration in Hrs
|
text |
|
|
205 |
[gas_expire] |
Expiry Management |
dropdown |
|
|
206 |
[gas_backup] |
Backup cylinders |
text |
|
|
207 |
[med_stock] |
Section Header: Essential Medicines
72-hr stock
|
dropdown |
|
|
208 |
[med_expire] |
Expiry Management |
dropdown |
|
|
209 |
[med_proc] |
Procurement plan |
text |
|
|
210 |
[food_suppl] |
Section Header: Food & Nutrition
72-hr stock?
|
dropdown |
|
|
211 |
[food_expire] |
Expiry Managemnet |
dropdown |
|
|
212 |
[food_supply] |
Emergency rations |
text |
|
|
213 |
[med_item] |
Section Header: Medical Equipment
Key Items
|
text |
|
|
214 |
[med_vents] |
Backup ventilators |
text |
|
|
215 |
[ambu_count] |
Section Header: Ambulances
Functional (Count)
|
text |
|
|
216 |
[ambu_fuel] |
Fuel Reserve for Ambulance (L) |
text |
|
|
217 |
[ambu_main] |
Maintenance |
text |
|
|
218 |
[emer_comms] |
Section Header: Communication Equipment
Communication Equipment
|
checkbox| 1 | emer_comms___1 | Telephone lines | | 2 | emer_comms___2 | 2-way radio | | 3 | emer_comms___3 | Internet |
|
|
|
219 |
[comms_backup] |
Backup power |
text |
|
|
220 |
[safety_equip] |
Section Header: Fire Safety Equipment
Safety Equipment
|
checkbox| 1 | safety_equip___1 | Extinguishers | | 2 | safety_equip___2 | Hydrants | | 3 | safety_equip___3 | Alarms |
|
|
|
221 |
[safety_insp] |
Last Inspection |
text (date_dmy) |
|
|
222 |
[water_sani] |
Section Header: E.3 Environmental Health & Hygiene Systems
Water, Sanitation & Hygiene (WASH)
|
radio (Matrix - ranking) |
|
|
223 |
[medical_waste] |
Medical Waste Management |
radio (Matrix - ranking) |
|
|
224 |
[hazardeous_material] |
Hazardous Material Handling |
radio (Matrix - ranking) |
|
|
225 |
[vector_con] |
Vector Control |
radio (Matrix - ranking) |
|
|
226 |
[epp] |
Environmental Protection Practices |
radio (Matrix - ranking) |
|
|
227 |
[food_safe] |
Food Safety |
radio (Matrix - ranking) |
|
|
228 |
[water_cap] |
Section Header: Water, Sanitation & Hygiene (WASH)
Toilet capacity
|
text |
|
|
229 |
[water_hand] |
Handwashing stations |
text |
|
|
230 |
[water_test] |
Water quality testing |
dropdown |
|
|
231 |
[waste_manage] |
Section Header: Medical Waste Management
3-bucket system
|
dropdown |
|
|
232 |
[waste_treat] |
Waste treatment |
text |
|
|
233 |
[hazard_handling] |
Section Header: Hazardous Material Handling
Chemical storage
|
text |
|
|
234 |
[vec_fre] |
Vector Control
Fogging/IRS frequency
|
text |
|
|
235 |
[envi_aware] |
Environmental Protection Practices
Awareness programs (Times/year)
|
text |
|
|
236 |
[food_pois] |
Food Safety
Food poisoning incidents
|
text |
|
|
237 |
[staff_demo] |
Section Header: SECTION F: HUMAN RESOURCES & CAPACITY BUILDING
F.1 Staffing & Demographics
|
descriptive |
|
|
238 |
[staff_doc] |
Doctors |
descriptive |
|
|
239 |
[staff_doc_num] |
Numbers |
text |
|
|
240 |
[staff_doc_per] |
% of Total Staff |
text |
|
|
241 |
[staff_doc_status] |
Status |
dropdown| 1 | Permanent | | 2 | Contractual | | 3 | Deputed |
|
|
|
242 |
[staff_doc_desi]
Show the field ONLY if:
[staff_doc_num] = ''
|
Designation |
dropdown| 1 | Medical Office | | 2 | Specialist |
|
|
|
243 |
[staff_doc_train] |
Disaster Training |
dropdown |
|
|
244 |
[staff_nurse] |
Nurses |
descriptive |
|
|
245 |
[staff_nurse_num] |
Numbers |
text |
|
|
246 |
[staff_nurse_per] |
% of Total Staff |
text |
|
|
247 |
[staff_nurse_status] |
Status |
dropdown| 1 | Permanent | | 2 | Contractual | | 3 | Deputed |
|
|
|
248 |
[satff_nurse_desi]
Show the field ONLY if:
[staff_nurse_num] = ''
|
Designation |
dropdown |
|
|
249 |
[staff_nurse_train] |
Disaster Training |
dropdown |
|
|
250 |
[staff_paramed] |
Paramedics/Technicians |
descriptive |
|
|
251 |
[staff_paramed_num] |
Numbers |
text |
|
|
252 |
[staff_paramed_per] |
% of Total Staff |
text |
|
|
253 |
[staff_paramed_status] |
Status |
dropdown| 1 | Permanent | | 2 | Contractual | | 3 | Deputed |
|
|
|
254 |
[staff_paramed_desi]
Show the field ONLY if:
[staff_paramed_num] = ''
|
Designation |
dropdown |
|
|
255 |
[staff_paramed_train] |
Disaster Training |
dropdown |
|
|
256 |
[staff_supp] |
Support Staff |
descriptive |
|
|
257 |
[staff_supp_num] |
Numbers |
text |
|
|
258 |
[staff_supp_per] |
% of Total Staff |
text |
|
|
259 |
[staff_supp_status] |
Status |
dropdown| 1 | Permanent | | 2 | Contractual | | 3 | Deputed |
|
|
|
260 |
[staff_supp_desi]
Show the field ONLY if:
[staff_supp_num] = ''
|
Designation |
dropdown |
|
|
261 |
[staff_supp_train] |
Disaster Training |
dropdown |
|
|
262 |
[staff_admin] |
Administrative Staff |
descriptive |
|
|
263 |
[staff_admin_num] |
Numbers |
text |
|
|
264 |
[staff_admin_per] |
% of Total Staff |
text |
|
|
265 |
[staff_admin_status] |
Status |
dropdown| 1 | Permanent | | 2 | Contractual | | 3 | Deputed |
|
|
|
266 |
[staff_admin_train] |
Disaster Training |
dropdown |
|
|
267 |
[staff_absent] |
Absenteeism during normal days in % |
text |
|
|
268 |
[staff_absebt_disaster] |
anticipated absenteeism during disaster in % |
text |
|
|
269 |
[indicator_1_20_2_40_3_50_4] |
Section Header: F.2 Disaster Awareness & Training
indicator 1= 20%, 2=40%, 3 =50%, 4=80%, 5=100%
|
descriptive |
|
|
270 |
[disaster_knowledge_score] |
Disaster Knowledge Level Staff Awareness |
dropdown| 1 | 1=< 10% | | 2 | 2=11-25% | | 3 | 3=26-50% | | 4 | 4=51-75% | | 5 | 5=>75% |
|
|
|
271 |
[disaster_knowledge_meth] |
Knowledge assessment method |
text |
|
|
272 |
[disaster_train_freq] |
Training Frequency |
dropdown| 1 | 1=Not conducted | | 2 | 2=Once in 5 years | | 3 | 3=Once in 2 years | | 4 | 4=Annually | | 5 | 5=6-monthly |
|
|
|
273 |
[disaster_train_date] |
Last training date |
text (date_dmy) |
|
|
274 |
[disaster_train_content] |
Training Content |
dropdown| 1 | CPR | | 2 | Fire Extinguisher | | 3 | Triage | | 4 | Evacuation | | 5 | Isolation | | 6 | Other |
|
|
|
275 |
[disaster_train_content_other]
Show the field ONLY if:
[disaster_train_content] = '6'
|
If Other |
text |
|
|
276 |
[disaster_train_participation] |
Training Participation |
dropdown| 1 | < 10% | | 2 | 11-25% | | 3 | 26-50% | | 4 | 51-75% | | 5 | 5=>75% |
|
|
|
277 |
[disaster_participant] |
Regular Participant |
text |
|
|
278 |
[disaster_drills] |
Disaster Preparedness Drills |
dropdown| 1 | None | | 2 | Rare | | 3 | Annual | | 4 | Biannual | | 5 | Quarterly |
|
|
|
279 |
[disaster_drills_date] |
Last Drill Date |
text (date_dmy) |
|
|
280 |
[disaster_disem] |
Disaster Plan Dissemination |
dropdown| 1 | None | | 2 | Low (some staff) | | 3 | Medium (most staff) | | 4 | High (all staff) | | 5 | Comprehensive (all + community) |
|
|
|
281 |
[disaster_disem_format] |
Format |
dropdown| 1 | IEC | | 2 | Manual | | 3 | Digital | | 4 | Verbal |
|
|
|
282 |
[disaster_preparedness] |
F.3 Disaster Preparedness Skills Assessment
For each skill, indicate % of staff trained (0-100%):
|
descriptive |
|
|
283 |
[disaster_cpr] |
CPR/BLS |
text |
|
|
284 |
[disaster_cpr_train]
Show the field ONLY if:
[disaster_cpr] = ''
|
Last Training |
text (date_dmy) |
|
|
285 |
[disaster_cpr_cert]
Show the field ONLY if:
[disaster_cpr] = ''
|
Certification |
radio |
|
|
286 |
[disaster_cpr_course]
Show the field ONLY if:
[disaster_cpr] = ''
|
Course |
text |
|
|
287 |
[disaster_firstaid] |
First Aid |
text |
|
|
288 |
[disaster_first_train]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Last Training |
text (date_dmy) |
|
|
289 |
[disaster_first_cert]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Certification |
radio |
|
|
290 |
[disaster_first_course]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Course |
text |
|
|
291 |
[disaster_safety] |
Fire Safety/Extinguisher Use |
text |
|
|
292 |
[disaster_safety_train]
Show the field ONLY if:
[disaster_safety] = ''
|
Last Training |
text (date_dmy) |
|
|
293 |
[disaster_safety_cert]
Show the field ONLY if:
[disaster_safety] = ''
|
Certification |
radio |
|
|
294 |
[disaster_safety_duration]
Show the field ONLY if:
[disaster_safety] = ''
|
Drills= Times/Year |
text |
|
|
295 |
[disaster_triage] |
Triage & Mass Casualty Management |
text |
|
|
296 |
[disaster_triage_train]
Show the field ONLY if:
[disaster_triage] = ''
|
Last Training |
text (date_dmy) |
|
|
297 |
[disaster_triage_cert]
Show the field ONLY if:
[disaster_triage] = ''
|
Certification |
radio |
|
|
298 |
[disaster_triage_protocol]
Show the field ONLY if:
[disaster_triage] = ''
|
Protocol |
text |
|
|
299 |
[disaster_infection] |
Isolation & Infection Control |
text |
|
|
300 |
[disaster_infection_train]
Show the field ONLY if:
[disaster_infection] = ''
|
Last Training |
text |
|
|
301 |
[disaster_infection_cert]
Show the field ONLY if:
[disaster_infection] = ''
|
Certification |
radio |
|
|
302 |
[disaster_infection_ppe]
Show the field ONLY if:
[disaster_infection] = ''
|
PPE Availability |
dropdown |
|
|
303 |
[disaster_haz] |
Hazmat/Chemical Decontamination |
text |
|
|
304 |
[disaster_haz_train]
Show the field ONLY if:
[disaster_haz] = ''
|
Last Training |
text (date_dmy) |
|
|
305 |
[disaster_haz_cert]
Show the field ONLY if:
[disaster_haz] = ''
|
Certification |
radio |
|
|
306 |
[disaster_haz_equip]
Show the field ONLY if:
[disaster_haz] = ''
|
Equipment |
text |
|
|
307 |
[disaster_psych] |
Psychosocial Support |
text |
|
|
308 |
[disaster_psych_train]
Show the field ONLY if:
[disaster_psych] = ''
|
Last Training |
text |
|
|
309 |
[disaster_psych_cert]
Show the field ONLY if:
[disaster_psych] = ''
|
Certification |
radio |
|
|
310 |
[disaster_psych_scope]
Show the field ONLY if:
[disaster_psych] = ''
|
Training scope |
text |
|
|
311 |
[disaster_swim] |
Swimming/Water Safety |
text |
|
|
312 |
[disaster_swim_train]
Show the field ONLY if:
[disaster_swim] = ''
|
Last Training |
text (date_dmy) |
|
|
313 |
[disaster_swim_cert]
Show the field ONLY if:
[disaster_swim] = ''
|
Certification |
radio |
|
|
314 |
[disaster_swim_flood]
Show the field ONLY if:
[disaster_swim] = ''
|
Relevance (flood-prone) |
radio |
|
|
315 |
[disaster_staff_incent] |
F.4 Staff Incentives & Motivation During Disasters |
descriptive |
|
|
316 |
[duty_incentive] |
Disaster Duty Incentives |
radio (Matrix - ranking) |
|
|
317 |
[leave_provision] |
Leave & Rest Provisions |
radio (Matrix - ranking) |
|
|
318 |
[psych_support] |
Psychological Support for Staff |
radio (Matrix - ranking) |
|
|
319 |
[disaster_staff_motivation_indicators] |
1=None; 2=< 10% salary; 3=10-20%; 4=21-40%; 5=>40% incentive
1=Rigid; 2=Limited; 3=Moderate; 4=Adequate; 5=Flexible & supportive
1=None; 2=Ad-hoc; 3=Some counseling; 4=Regular support; 5=Integrated program
|
descriptive |
|
|
320 |
[disaster_incent_policy] |
Policy |
text |
|
|
321 |
[disaster_duty_plan] |
Rotation Planned |
dropdown |
|
|
322 |
[disaster_staff_counsel] |
Counselor availability |
text |
|
|
323 |
[disaster_governance] |
Section Header: SECTION G: INSTITUTIONAL ARRANGEMENTS & ORGANIZATIONAL CAPACITY
G.1 Hospital Disaster Committee & Governance
|
text |
|
|
324 |
[disaster_esta] |
Formal Establishment |
dropdown |
|
|
325 |
[disaster_est_doc] |
Terms of reference document |
dropdown |
|
|
326 |
[dsiaster_govern_committee] |
Committee Composition |
checkbox| 1 | dsiaster_govern_committee___1 | Medical Superintendent | | 2 | dsiaster_govern_committee___2 | Safety Officer | | 3 | dsiaster_govern_committee___3 | Matron | | 4 | dsiaster_govern_committee___4 | Pharmacist | | 5 | dsiaster_govern_committee___5 | Radiologist | | 6 | dsiaster_govern_committee___6 | Admin Head | | 7 | dsiaster_govern_committee___7 | Staff Rep | | 8 | dsiaster_govern_committee___8 | Community Rep |
|
|
|
327 |
[disaster_govern_cord] |
Designated Coordinator |
text |
|
|
328 |
[disaster_govern_profile] |
Job Profile |
dropdown |
|
|
329 |
[disaster_govern_dm_meet] |
Coordination with District DM Authority |
dropdown| 1 | None | | 2 | Poor | | 3 | Moderate | | 4 | Good | | 5 | Excellent |
|
|
|
330 |
[disaster_govern_dm_meet_freq] |
Meeting Frequency |
text |
|
|
331 |
[disaster_govern_stake] |
Stakeholder Engagement |
checkbox| 1 | disaster_govern_stake___1 | Health officials | | 2 | disaster_govern_stake___2 | NGOs | | 3 | disaster_govern_stake___3 | Local government | | 4 | disaster_govern_stake___4 | Police/Fire | | 5 | disaster_govern_stake___5 | Community |
|
|
|
332 |
[disaster_govern_stake_freq] |
Meeting Frequency |
text |
|
|
333 |
[icc] |
G.2 Incident Command Centre (ICC) |
descriptive |
|
|
334 |
[space_design] |
Space Designation |
radio (Matrix - ranking) |
|
|
335 |
[physical_secure] |
Physical Security |
radio (Matrix - ranking) |
|
|
336 |
[comms_equipment] |
Communication Equipments |
radio (Matrix - ranking) |
|
|
337 |
[backup_light] |
Back Up Power and Lightning |
radio (Matrix - ranking) |
|
|
338 |
[computer_it] |
Computer system and Software |
radio (Matrix - ranking) |
|
|
339 |
[telephone_direct] |
Telephone Directory |
radio (Matrix - ranking) |
|
|
340 |
[supplies_furni] |
Supplies and Furniture |
radio (Matrix - ranking) |
|
|
341 |
[icc_space_location] |
Space Designation Location |
text |
|
|
342 |
[icc_security] |
Distance from main building |
text |
|
|
343 |
[icc_telephone] |
Telephone lines |
descriptive |
|
|
344 |
[icc_telephone_radio] |
2-way Radios |
dropdown |
|
|
345 |
[icc_telehone_net] |
Internet |
dropdown |
|
|
346 |
[icc_backup_ups] |
UPS backup in Hrs |
text |
|
|
347 |
[icc_computer_it_database] |
Patient Database backedup |
dropdown |
|
|
348 |
[icc_emergency_no] |
Emergency Number |
text |
|
|
349 |
[disaster_management_plan] |
G.3 Disaster Management Plans & Standard Operating Procedures |
descriptive |
|
|
350 |
[sops] |
SOPs & Protocols |
radio (Matrix - ranking) |
|
|
351 |
[disaster_codes] |
Disaster Codes (Color/Number System) |
radio (Matrix - ranking) |
|
|
352 |
[staff_action_card] |
Staff Action Cards |
radio (Matrix - ranking) |
|
|
353 |
[triage_protocol] |
Triage Protocol |
radio (Matrix - ranking) |
|
|
354 |
[hdmp_indicators] |
SOPs & Protocols 1=None; 2=Basic; 3=Comprehensive; 4=Detailed & tested; 5=Dynamic & regularly updated
Disaster Codes (Color/Number System) 1=Not defined; 2=Defined only; 3=Defined & trained; 4=Displayed; 5=Operational with drills
Staff Action Cards 1=Absent; 2=Few; 3=Partial distribution; 4=All staff; 5=All staff + reviewed
Triage Protocol 1=Absent; 2=Basic; 3=Established; 4=Tested; 5=Functional & exercised
|
descriptive |
|
|
355 |
[hdmp_status] |
Hospital Disaster Management Plan (HDMP) |
dropdown |
|
|
356 |
[hdmp_version] |
HDMP version date |
text (date_dmy) |
|
|
357 |
[idsdmp_status] |
Integration with District/State DM Plan |
dropdown |
|
|
358 |
[idsmp_alingmnet] |
Alingment |
text |
|
|
359 |
[sops_area] |
SOPS and Protocols Area covered |
text |
|
|
360 |
[color_code_definition] |
Disaster Codes (Color/Number System), Code definition |
text |
|
|
361 |
[actioncard_distribution] |
Staff Action Cards Distribution |
dropdown |
|
|
362 |
[supplylist_location] |
Pre-positioned Supplies List Location |
text |
|
|
363 |
[triage_code_category] |
Triage Categories |
checkbox| 1 | triage_code_category___1 | Red | | 2 | triage_code_category___2 | Yellow | | 3 | triage_code_category___3 | Green | | 4 | triage_code_category___4 | Black |
|
|
|
364 |
[mock_drills_and_exercise] |
G.4 Mock Drills & Exercises |
descriptive |
|
|
365 |
[mock_drill_date] |
Last Mock Drill Date |
text (date_dmy) |
|
|
366 |
[mock_drill_type]
Show the field ONLY if:
[mock_drill_date] = ''
|
Mock Drill Type |
checkbox| 1 | mock_drill_type___1 | Earthquack | | 2 | mock_drill_type___2 | Flood | | 3 | mock_drill_type___3 | Fire | | 4 | mock_drill_type___4 | MCI | | 5 | mock_drill_type___5 | Other |
|
|
|
367 |
[drill_frequency_schedule] |
Drill Frequency Planned schedule |
text |
|
|
368 |
[drill_frequncy] |
Drill Frequency |
radio (Matrix - ranking)| 1 | None | | 2 | Rare | | 3 | Annual | | 4 | Biannual | | 5 | Quarterly |
|
|
|
369 |
[drill_duration] |
Drill Duration in Hrs |
text |
|
|
370 |
[drill_exercise]
Show the field ONLY if:
[drill_duration] = ''
|
Real-time exercise |
dropdown |
|
|
371 |
[drill_participant] |
Partcipants |
checkbox| 1 | drill_participant___1 | Staff | | 2 | drill_participant___2 | Community | | 3 | drill_participant___3 | External Agencies | | 4 | drill_participant___4 | Media |
|
|
|
372 |
[drill_partcipant_attendance] |
Attendance in % |
text |
|
|
373 |
[variation_identified] |
Rate How many issues found during drills |
text |
|
|
374 |
[infrastructure] |
Infrastructure |
radio (Matrix - ranking) |
|
|
375 |
[manpower] |
Manpower |
radio (Matrix - ranking) |
|
|
376 |
[supplies_material] |
Material Supplies |
radio (Matrix - ranking) |
|
|
377 |
[training_gaps] |
Training Gaps |
radio (Matrix - ranking) |
|
|
378 |
[process_procedure] |
Process/Procedure |
radio (Matrix - ranking) |
|
|
379 |
[procrument_issue] |
Procrument Issues |
radio (Matrix - ranking) |
|
|
380 |
[debrief_improve] |
Debriefing and Improvement |
descriptive |
|
|
381 |
[debrief_improvement] |
Debrief and Improvement |
radio (Matrix - ranking)| 1 | Not done | | 2 | Informal | | 3 | Documented | | 4 | Action plan | | 5 | Action plan implemented & monitored |
|
|
|
382 |
[debrief_minutes_avail] |
Minutes Available |
dropdown |
|
|
383 |
[postdrill_report] |
Post Drill report |
dropdown |
|
|
384 |
[postdrill_reprot_date] |
Date |
text (date_dmy) |
|
|
385 |
[mcmr] |
G.5 Mass Casualty Management Readiness |
descriptive |
|
|
386 |
[capacity_planing] |
Surge Capacity Planning |
radio (Matrix - ranking) |
|
|
387 |
[triage_areas] |
Triage Area Setup |
radio (Matrix - ranking) |
|
|
388 |
[casualty_flow] |
Casualty Management Flow |
radio (Matrix - ranking) |
|
|
389 |
[morgue_facility] |
Morgue/Mortuary Facilities |
radio (Matrix - ranking) |
|
|
390 |
[psycho_first_aids] |
Psychological First Aid for Victims |
radio (Matrix - ranking) |
|
|
391 |
[familt_comms_information] |
Family Support/Information System |
radio (Matrix - ranking) |
|
|
392 |
[mass_indicators] |
Surge Capacity Planning 1=Not planned; 2=Basic; 3=Outlined; 4=Detailed; 5=Tested through drills
Triage Area Setup 1=Not designated; 2=Identified; 3=Partially prepared; 4=Well-designed; 5=Functional & stocked
Casualty Management Flow 1=Undefined; 2=Basic; 3=Documented; 4=Trained; 5=Practiced & monitored
Morgue/Mortuary Facilities 1=Inadequate; 2=Minimal; 3=Moderate; 4=Good; 5=Adequate with contingency
Psychological First Aid for Victims 1=Not available; 2=Ad-hoc; 3=Some provision; 4=Trained personnel; 5=Integrated support
Family Support/Information System 1=Not planned; 2=Basic; 3=Outlined; 4=Detailed; 5=Tested & functional
|
descriptive |
|
|
393 |
[mass_surge_capacity_assum] |
Assumed Casualty Numbers |
text |
|
|
394 |
[triage_area] |
Triage Area setup Area size (m²) |
text |
|
|
395 |
[morgue_capacity] |
Morgue/Mortuary Facilities capacity |
text |
|
|
396 |
[psych_first_aid] |
Personnel trained Psychological First Aid for Victims |
text |
|
|
397 |
[family_communication] |
Family Support/Information System Communication method |
text |
|
|
398 |
[budget_allocation_for_disaster_managemnet] |
Section Header: SECTION H: INSTITUTIONAL CONDITIONS & RESOURCES
H.1 Budget Allocation for Disaster Management
|
descriptive |
|
|
399 |
[prepare_planning_amount] |
Section Header: Preparedness & Planning
Amount Allocated (₹)
|
text |
|
|
400 |
[prepare_amount_per] |
% of Total Budget |
text |
|
|
401 |
[preparedness_status] |
Status |
dropdown |
|
|
402 |
[infra_maintance_amount] |
Section Header: Infrastructure & Maintenance
Amount Allocated (₹)
|
text |
|
|
403 |
[infra_main_amount_per] |
% of Total Budget |
text |
|
|
404 |
[infra_main_status] |
Status |
dropdown |
|
|
405 |
[equip_supply_amount] |
Section Header: Equipment & Supplies
Amount Allocated (₹)
|
text |
|
|
406 |
[equip_supply_amount_per] |
% of Total Budget |
text |
|
|
407 |
[euip_supply_amount_status] |
Status |
dropdown |
|
|
408 |
[comms_amount] |
Section Header: Communication Systems
Amount Allocated (₹)
|
text |
|
|
409 |
[comms_amount_per] |
% of Total Budget |
text |
|
|
410 |
[comms_amount_status] |
Status |
dropdown |
|
|
411 |
[commu_engage_amount] |
Section Header: Community Engagement
Amount Allocated (₹)
|
text |
|
|
412 |
[comm_engage_amount_per] |
% of Total Budget |
text |
|
|
413 |
[comm_engage_amount_status] |
Status |
dropdown |
|
|
414 |
[external_collab_amount] |
Section Header: External Collaboration
Amount Allocated (₹)
|
text |
|
|
415 |
[extternal_collab_amount_per] |
% of Total Budget |
text |
|
|
416 |
[external_collab_status] |
Status |
dropdown |
|
|
417 |
[post_disas_recover_amount] |
Section Header: Post Disaster Recovery
Amount Allocated (₹)
|
text |
|
|
418 |
[post_disas_recover_amount_per] |
% of Total Budget |
text |
|
|
419 |
[post_disas_recover_status] |
Status |
dropdown |
|
|
420 |
[total] |
Total Budget Amount |
calc
Calculation: if(isblankormissingcode([prepare_planning_amount]),0,[prepare_planning_amount]) +
if(isblankormissingcode([infra_maintance_amount]),0,[infra_maintance_amount]) +
if(isblankormissingcode([equip_supply_amount]),0,[equip_supply_amount]) +
if(isblankormissingcode([comms_amount]),0,[comms_amount]) +
if(isblankormissingcode([commu_engage_amount]),0,[commu_engage_amount]) +
if(isblankormissingcode([external_collab_amount]),0,[external_collab_amount]) +
if(isblankormissingcode([post_disas_recover_amount]),0,[post_disas_recover_amount])
|
|
|
421 |
[national_gov] |
Section Header: H.2 Resource Mobilization
National Government
|
radio |
|
|
422 |
[resource_mobile_nation_gov] |
Schemes/Grants |
text |
|
|
423 |
[state_gov] |
State Government |
radio |
|
|
424 |
[resource_mobile_state_gov] |
Funding/Support |
text |
|
|
425 |
[district_admin] |
Districts Administration |
radio |
|
|
426 |
[resource_mobile_dis_admin_cordi] |
Coordination |
text |
|
|
427 |
[ngo_organization] |
NGOs/CSR Organizations |
radio |
|
|
428 |
[resource_mobile_ngo_partner] |
Partnerships |
text |
|
|
429 |
[private_sec] |
Private Sector |
radio |
|
|
430 |
[resource_mobile_private_sec_sponsr] |
Sponsrship/Donations |
text |
|
|
431 |
[intern_agencies] |
International Agencies |
radio |
|
|
432 |
[resource_mobile_intern_agency_support] |
Funding/Technical support |
text |
|
|
433 |
[comm_local_agency] |
Community/ local resources |
radio |
|
|
434 |
[resource_mobil_commu_support] |
Volunteers/ Donations |
text |
|
|
435 |
[resour_mobile_indicator] |
Support Received (1=No support, 5=Best support) |
descriptive |
|
|
436 |
[meet_health_off] |
Section Header: H.3 Inter-Agency Coordination & Collaboration
Meetings with Health Officials
|
radio |
|
|
437 |
[meet_dm] |
District Health Officer |
dropdown |
|
|
438 |
[cord_dm_autho] |
Coordination with District DM Authority |
radio |
|
|
439 |
[state_dm_intergration] |
State DM plan integration |
dropdown |
|
|
440 |
[lias_police_fire] |
Liaison with Police/Fire Department |
radio |
|
|
441 |
[police_fire_dpt_cordin_exer] |
Cordination exercise |
dropdown |
|
|
442 |
[engage_ngo] |
Engagement with NGOs/Red Cross |
radio |
|
|
443 |
[ngo_memo_under] |
Memoranda of Understanding |
dropdown |
|
|
444 |
[collab_local_gov] |
Collaboration with Local Government |
radio |
|
|
445 |
[local_gov_collab] |
Gram Panchayat |
dropdown |
|
|
446 |
[intra_interfacility] |
Intra/Inter-Facility Communication |
radio |
|
|
447 |
[intr_facility_resource_share] |
Resource-sharing network |
dropdown |
|
|
448 |
[int_age_col_fre] |
Frequency (1=Not conducted, 5=Monthly) |
descriptive |
|
|
449 |
[meet_official] |
Section Header: Inter-Agency Coordination & Collaboration
Meetings with Health Officials
|
radio (Matrix - ranking) |
|
|
450 |
[cord_dm_auth] |
Coordination with District DM Authority |
radio (Matrix - ranking) |
|
|
451 |
[liasion_police_fire] |
Liaison with Police/Fire Department |
radio (Matrix - ranking) |
|
|
452 |
[engage_ngo_redcross] |
Engagement with NGOs/Red Cross |
radio (Matrix - ranking) |
|
|
453 |
[colla_local_gov] |
Collaboration with Local Government |
radio (Matrix - ranking) |
|
|
454 |
[int_facility_comms] |
Intra/Inter-Facility Communication |
radio (Matrix - ranking) |
|
|
455 |
[int_age_colab_quality] |
Quality (1=Poor, 5=Excellent) |
descriptive |
|
|
456 |
[comm_disa_aware] |
Section Header: SECTION I: COMMUNITY ENGAGEMENT & EARLY WARNING SYSTEMS
I.1 Community Disaster Awareness & Participation
|
descriptive |
|
|
457 |
[indicator_awareness_meetin] |
Indicator
Awareness Meeting Frequency 1=Not conducted; 2=Once/year; 3=6-monthly; 4=Quarterly; 5=Monthly
Training Quality for Community 1=Not conducted; 2=Informal; 3=Hands-on; 4=Lectures + hands-on; 5=IEC materials + drills
Community Participation in DM Activities 1=No participation; 2=Low; 3=Moderate; 4=High; 5=Very high
Plan Sharing with Community 1=No sharing; 2=Low; 3=Medium; 4=High; 5=Very high (IEC materials available)
Support from CBOs/NGOs 1=No support; 2=Poor; 3=Moderate; 4=High; 5=Best
|
descriptive |
|
|
458 |
[awareness_meeting_frequenc] |
Awareness Meeting Frequency |
radio |
|
|
459 |
[attendance] |
Attendance |
text |
|
|
460 |
[training_quality_for_commu] |
Training Quality for Community |
radio |
|
|
461 |
[participants] |
Participants |
text |
|
|
463 |
[activities] |
Activities |
text |
|
|
464 |
[plan_sharing_with_communit] |
Plan Sharing with Community |
radio |
|
|
465 |
[formats] |
Formats |
checkbox| 1 | formats___1 | Posters | | 2 | formats___2 | Flyers | | 3 | formats___3 | Videos | | 4 | formats___4 | Meetings |
|
|
|
466 |
[support_from_cbos_ngos] |
Support from CBOs/NGOs |
radio |
|
|
467 |
[organizations] |
Organizations |
text |
|
|
468 |
[i_2_early_warning_system_n] |
I.2 Early Warning System & Notification |
descriptive |
|
|
469 |
[early_warning_indicators] |
Early Warning Reception System 1=Absent; 2=Poor (< 24 hrs); 3=Moderate (3 days); 4=Good (5 days); 5=Best (7+ days)
Early Warning Dissemination 1=Not equipped; 2=Low; 3=Moderate; 4=High; 5=Very well equipped
Community Notification System 1=Absent; 2=Poor; 3=Moderate; 4=High; 5=Best (timely, clear, actionable)
|
descriptive |
|
|
470 |
[early_warning_reception_sy] |
Early Warning Reception System |
radio |
|
|
471 |
[source] |
Source: |
dropdown| 1 | District/State authority | | 2 | Meteorological |
|
|
|
472 |
[early_warning_disseminatio] |
Early Warning Dissemination |
radio |
|
|
474 |
[method] |
Method |
dropdown| 1 | SMS | | 2 | Call | | 3 | Siren | | 4 | Radio | | 5 | Other |
|
|
|
475 |
[if_other]
Show the field ONLY if:
[method] = '5'
|
if other |
text |
|
|
476 |
[ews_testing_drills] |
EWS Testing & Drills |
radio |
|
|
477 |
[if_ews_testing_and_drills] |
if EWS Testing and Drills |
dropdown |
|
|
478 |
[if_yes_frequency_year]
Show the field ONLY if:
[if_ews_testing_and_drills] = '1'
|
If yes (Frequency/Year) |
text |
|
|
479 |
[last_test_date] |
Last test Date |
text (date_dmy) |
|
|
480 |
[k_1_key_strengths_list_3_5] |
Section Header: SECTION K: STRENGTHS, GAPS & RECOMMENDATIONS
K.1 Key Strengths
List 3-5 major strengths identified in the facility's disaster preparedness:
|
notes |
|
|
481 |
[identify_priority_gaps_tha] |
Section Header: K.2 Critical Gaps & Areas of Concern
Identify priority gaps that require immediate attention
|
descriptive |
|
|
482 |
[gap_1] |
Gap 1 |
notes |
|
|
483 |
[impact]
Show the field ONLY if:
[gap_1] = ''
|
Impact |
radio |
|
|
484 |
[recommended_action]
Show the field ONLY if:
[gap_1] = ''
|
Recommended Action |
notes |
|
|
485 |
[timeline]
Show the field ONLY if:
[gap_1] = ''
|
Timeline |
text |
|
|
486 |
[gap2] |
Gap2 |
notes |
|
|
487 |
[impact2]
Show the field ONLY if:
[gap2] = ''
|
Impact |
radio |
|
|
488 |
[recommended_action_2]
Show the field ONLY if:
[gap2] = ''
|
Recommended Action 2 |
notes |
|
|
489 |
[timeline_2]
Show the field ONLY if:
[gap2] = ''
|
timeline 2 |
text |
|
|
490 |
[gap_3] |
Gap 3 |
notes |
|
|
491 |
[impact_3]
Show the field ONLY if:
[gap_3] = ''
|
Impact 3 |
radio |
|
|
492 |
[recommended_action_3]
Show the field ONLY if:
[gap_3] = ''
|
Recommended Action 3 |
notes |
|
|
493 |
[timeline_3]
Show the field ONLY if:
[gap_3] = ''
|
Timeline 3 |
text |
|
|
494 |
[gap_4] |
Gap 4 |
notes |
|
|
495 |
[impact_4] |
Impact 4 |
radio |
|
|
496 |
[recommended_action_4] |
Recommended Action 4 |
notes |
|
|
497 |
[timeline_4] |
Timeline 4 |
text |
|
|
498 |
[short_term_0_3_months] |
Section Header: K.3 Recommendations for Strengthening Preparedness
Short Term (0-3 months)
|
notes |
|
|
499 |
[medium_term_3_12_months] |
Medium-term (3-12 months) |
notes |
|
|
500 |
[long_term_1_2_years] |
Long-term (1-2 years) |
notes |
|
|
501 |
[general_observation] |
Section Header: SECTION L: ASSESSOR NOTES & OBSERVATIONS
General ObservationProvide a narrative summary of key observations during the assessment:
|
notes |
|
|
502 |
[challenges_encountered_dur] |
Challenges Encountered During Assessment |
notes |
|
|
503 |
[follow_up_actions_required] |
Follow-up Actions Required |
notes |
|
|
504 |
[facility_representative_co] |
Facility Representative Comments/Clarifications |
notes |
|
|
505 |
[name_designation] |
Section Header: SECTION M: ASSESSMENT COMPLETION CERTIFICATION
Name & DesignationAssessment Completed By:
|
text |
|
|
506 |
[signature] |
Signature |
file (signature) |
|
|
507 |
[assessment_date] |
Date |
text (date_dmy) |
|
|
508 |
[contact_phone] |
Contact Phone |
text |
|
|
509 |
[contact_email] |
Contact email |
text |
|
|
510 |
[name_and_designation] |
Section Header: Facility Representative/Authorized Signatory
Name and Designation
|
text |
|
|
511 |
[authorize_sign] |
Authorize Sign |
file (signature) |
|
|
512 |
[auth_date] |
Date |
text (date_dmy) |
|
|
513 |
[witness_name_and_designation] |
Name And Designation |
text |
|
|
514 |
[witness_signature] |
Witness Signature |
file (signature) |
|
|
515 |
[witness_dates] |
Witness Date |
text (date_dmy) |
|
|
516 |
[hdraform_complete] |
Section Header: Form Status
Complete?
|
dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
|
|
|
517 |
[information_sheet] |
Information Sheet for Healthcare Facility Participants
Who Am I?
My name is Nidhi Yadav, and I am a doctoral researcher at IIHMR University, Jaipur. I am conducting research to explore the factors influencing disaster preparedness and response in healthcare facilities, with emphasis on both organizational readiness (hospital-level) and vulnerability assessment (facility resilience to natural hazards).
Why This Research?
Healthcare organizations face increasing threats from natural and man-made disasters. The frequency of mass casualty incidents (earthquakes, floods, epidemics, etc.) has underscored the need for comprehensive preparedness planning. Most existing research focuses on system-level responses rather than facility-specific and individual responses. This study addresses this gap by assessing disaster preparedness among healthcare facilities in India, integrating organizational capacity with hazard vulnerability assessment.
What Is This Tool?
This combined assessment tool merges two complementary frameworks:
• Organizational-level assessment: Facility infrastructure, human resources, institutional arrangements, disaster management planning, and drills.
• Hazard Risk Assessment: Exposure to natural/environmental hazards, surrounding vulnerabilities, and resilience across five dimensions (physical, human resources, institutional, social, natural).
Who Is Being Invited?
You are invited because your healthcare facility plays a critical role in community disaster response. Whether you are a hospital, primary health center, or community health facility, your participation will help develop evidence-based recommendations for disaster preparedness in Indian healthcare settings.
What Does Participation Involve?
Duration: Approximately 60-90 minutes
Process: A structured questionnaire combining open-ended responses (facility details, observations) and scored indicators (1-5 scale assessing preparedness levels).
Confidentiality: All information is anonymous and strictly confidential. Your facility's identity will not be disclosed. Data will be securely stored and destroyed upon thesis completion or earlier upon request.
Voluntary Nature: You may skip any question, withdraw at any time without penalty, and modify responses during the interview.
Potential Risks
You may feel uncomfortable answering questions about gaps in disaster preparedness or past incidents. However, these assessments are designed to improve preparedness, not to assign blame. All responses are confidential and will not be used for regulatory compliance audits or punitive purposes.
Benefits
• Facility-level: Understand your preparedness strengths and gaps; actionable recommendations for improvement.
• Research-level: Findings will inform national and state disaster management policies and healthcare facility design standards.
• Recognition: Your participation contributes to building a more resilient healthcare system.
You will receive a small token of appreciation upon completion of the assessment.
Confidentiality & Data Protection
All information is treated as confidential and will be kept securely protected. No individual facility will be identifiable in publications or thesis. Data will be:
• Stored on password-protected devices
• Accessed only by research personnel
• Destroyed within one year of thesis completion
• Never shared with external agencies or used for regulatory action
Questions & Further Information
If you have questions now or later:
• Contact Researcher: nidhi@iihmrdelhi.edu.in, nidhiyadav5gmail.com | 9717322240
• Contact Research Guide: IIHMR Delhi
• Ethics Concerns: IRB, IIHMR Delhi
|
descriptive |
|
|
518 |
[information_sheet_complete] |
Section Header: Form Status
Complete?
|
dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
|
Add users
Remove users
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