|
|
1 |
[record_id] |
Record ID |
text |
|
|
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
|
descriptive |
|
|
3 |
[id] |
Study Number |
text, Required |
|
|
4 |
[healthcare_fac_name] |
Name of Healthcare Facility |
text, Required |
|
|
5 |
[fac_address] |
Address of Facility |
notes, Required |
|
|
6 |
[fac_head] |
Head of Institution Name & Designation |
notes |
|
|
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.
|
text (date_dmy), Required, Identifier |
|
|
8 |
[fac_representative] |
Facility Representative |
file (signature) |
|
|
9 |
[sign_date] |
Date |
text (date_dmy), Required, Identifier |
|
|
10 |
[reprsentative_name] |
Name and Designation |
text, Required |
|
|
11 |
[investigator_sign] |
PI/Investigator Signature |
file (signature), Required, Identifier |
|
|
12 |
[date] |
Date |
text (date_dmy), Required, Identifier |
|
|
13 |
[investigator_name] |
Investigator Name |
text |
|
|
14 |
[witness_sign] |
Witness Signature |
file (signature) |
|
|
15 |
[witness_date] |
Date |
text (date_dmy) |
|
|
16 |
[witness_name] |
Witness Name |
text |
|
|
17 |
[fac_name] |
Section Header: SECTION B: FACILITY DEMOGRAPHICS & GENERAL INFORMATION
Facility name
|
text, Required |
|
|
18 |
[fac_type] |
Facility Type |
radio| 1 | Hospital | | 2 | Primary Health Center | | 3 | Community Health Center | | 4 | Other |
|
|
|
19 |
[if_other_fac_type]
Show the field ONLY if:
[fac_type] = '4'
|
If other |
text |
|
|
20 |
[fac_add] |
Address (Full) |
text, Required |
|
|
21 |
[fac_location] |
City/District/State |
notes, Required |
|
|
22 |
[fac_contact] |
Contact Number |
text |
|
|
23 |
[date_assessment] |
Date |
text (date_dmy), Required, Identifier |
|
|
24 |
[fac_contact_detail] |
Email and Website |
text (email) |
|
|
25 |
[fac_est_year] |
Establishment Year |
text |
|
|
26 |
[fac_accreditation] |
NABH/NRHM/Other Accreditation |
radio, Required, Identifier |
|
|
27 |
[fac_recognised_by] |
Accreditation Body |
text |
|
|
28 |
[fac_item] |
Total Number of Beds |
text, Required |
|
|
29 |
[fac_occupancy] |
Hospital Occupancy Rate |
text, Required, Identifier |
|
|
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 | OT | | 7 | fac_services___7 | Isolation Ward | | 8 | fac_services___8 | Other(specify): |
|
|
|
31 |
[if_other_depr]
Show the field ONLY if:
[fac_services(6)] = '1'
|
if other |
text |
|
|
32 |
[key_person] |
Key Personals Present (Name & Designation) |
notes |
|
|
33 |
[fac_discription] |
Facility Description |
notes |
|
|
34 |
[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").
|
descriptive |
|
|
35 |
[earthquakes] |
Section Header: C.1 Geological HazardsGeological Hazard
Earthquakes
|
checkbox| 1 | earthquakes___1 | Very Severe | | 2 | earthquakes___2 | High | | 3 | earthquakes___3 | Moderate | | 4 | earthquakes___4 | Low | | 5 | earthquakes___5 | Not Severe |
|
|
|
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 |
|
|
|
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 |
|
|
|
38 |
[geo_hazard_other] |
if Other, geological hazards (e.g. rockfalls, subsidence, debris and mudflows,) |
text |
|
|
39 |
[earthquake] |
Section Header: Geo_Frequency
Earthquakes
|
radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
|
|
|
40 |
[landslide] |
Land Slides |
radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
|
|
|
41 |
[othes] |
Other |
radio (Matrix - ranking)| 1 | Very frequent | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequent |
|
|
|
42 |
[observation] |
Observations (e.g., past events, distance to epicenter)
Details:
Recent tremors
Proximity to unstable slopes
|
descriptive |
|
|
43 |
[earthquake_observation] |
Earthquake |
text |
|
|
44 |
[land_slide_observation] |
Land Slide |
text |
|
|
45 |
[other_observation] |
Other |
text |
|
|
46 |
[floods] |
Section Header: C.2 Hydro-Meteorological Hazards
Floods (Riverine/Urban)
|
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
47 |
[rainfall] |
Heavy Rainfall/Storm Surge |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
48 |
[erosion] |
River Erosion |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
49 |
[heatwave] |
Heat Wave |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
50 |
[cyclone] |
Cyclone/Storm |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
51 |
[hydro_other] |
Other |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
52 |
[hydro_others] |
If Hydro Other, (e.g. Avalanches, Cloud Burst) |
text |
|
|
53 |
[flood_frequency] |
Section Header: Hydro_Hazard_Frequency
Floods (Riverine/Urban)
|
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
54 |
[rainfall_frequency] |
Heavy Rainfall/Storm Surge |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
55 |
[erosion_frequency] |
River Erosion |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
56 |
[heatwave_frequency] |
Heat Wave |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
57 |
[cyclone_frequency] |
Cyclone/Storm |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
58 |
[other_frequency] |
Other |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not frequently |
|
|
|
59 |
[flood] |
Last Flood |
text (date_dmy), Required |
|
|
60 |
[flood_duration] |
Inundation depth/duration |
text |
|
|
61 |
[river_dist] |
Distance to river |
text |
|
|
62 |
[river_risk] |
Erosion Risk |
yesno |
|
|
63 |
[heat_wave] |
Heat Wave Duration |
text |
|
|
64 |
[cyclone_freq] |
Cyclone Seasonal occurrence |
yesno |
|
|
65 |
[epidemeological_risk] |
Section Header: C.3 Environmental & Biological Hazards
Epidemic/Pandemic Risk
|
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
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 |
|
|
|
67 |
[water_con] |
Water Contamination |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
68 |
[air_pollu] |
Air Pollution |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
69 |
[animal_incident] |
Snake/Animal Bite Incidents |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
70 |
[other_envior_hazard] |
Other (specify) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
71 |
[if_other_environment_and_b] |
if other, environment and biological Hazard |
text |
|
|
72 |
[risk_type] |
Type of Risk |
dropdown (autocomplete) |
|
|
73 |
[affected_risk] |
Affected |
dropdown (autocomplete) |
|
|
74 |
[vector_name] |
Endemic Species |
text |
|
|
75 |
[water_contamination] |
Water Contamination Source |
text |
|
|
76 |
[air_sources] |
Air Pollution Sources |
text |
|
|
77 |
[bite_frequency] |
Animal Bites frequency |
text |
|
|
78 |
[industrial_hazard] |
Section Header: C.4 Technological & Chemical Hazards
Industrial Accidents/Spills
|
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
79 |
[transportational_hazard] |
Hazardous Material Transportation |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
80 |
[fire_hazard] |
Fire Risk (external) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
81 |
[explosive_hazard] |
Explosions |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
82 |
[other_chemical] |
Other (specify) |
radio (Matrix - ranking)| 1 | Very Severe | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Severe |
|
|
|
83 |
[other_industrial] |
if Other Industrial Hazard |
text |
|
|
84 |
[dist_industry] |
Proximity to refineries\industries (in KM) |
text |
|
|
85 |
[facility_route] |
Routes to Facility |
dropdown |
|
|
86 |
[nearby_surrounding] |
Surrounding Structures |
dropdown |
|
|
87 |
[dist_site] |
Proximity to Hazardous site (in Km) |
text |
|
|
88 |
[civil_unrest] |
Section Header: C.5 Social & Anthropogenic Hazards
Civil Unrests\ Armed Conflict
|
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
|
|
|
89 |
[displacement] |
Displaced Population |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
|
|
|
90 |
[mass_gathering] |
Mass Gatherings |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
|
|
|
91 |
[social_other] |
Others |
radio (Matrix - ranking)| 1 | Very High | | 2 | High | | 3 | Moderate | | 4 | Low | | 5 | Not Happened |
|
|
|
92 |
[other_anthropogenic] |
if Other Anthropogenic Hazard |
text |
|
|
93 |
[civil_conflicts] |
History of Civil unrest |
text |
|
|
94 |
[facility_impact] |
Displacement cause Impact on Facility |
text |
|
|
95 |
[mass_gathering_proximity] |
Proximity of Gathering (in Km) |
text |
|
|
96 |
[maa_gathering_frequency] |
Frequency of Gathering |
radio| 1 | Frequent | | 2 | Occasional | | 3 | Once a while |
|
|
|
97 |
[village_distance] |
Section Header: C.6 Surrounding Environment & Infrastructure Proximity
Village/Settlement (in KM)
|
text |
|
|
98 |
[village_density]
Show the field ONLY if:
[village_distance] = ''
|
Population density |
text |
|
|
99 |
[shelter_proximity] |
School/Community Center (shelter potential) (in KM) |
text |
|
|
100 |
[shelter_capacity]
Show the field ONLY if:
[shelter_proximity] = ''
|
Capacity |
text |
|
|
101 |
[civil_service_office] |
Police/Fire Station (in Km) |
text |
|
|
102 |
[service_response_time]
Show the field ONLY if:
[civil_service_office] = ''
|
Response time |
text |
|
|
103 |
[mode_transportation] |
Major Transportation Hub (in Km) |
text |
|
|
104 |
[transportation_mode]
Show the field ONLY if:
[mode_transportation] = ''
|
Mode |
text |
|
|
105 |
[hazardous_site] |
Hazardous Facility (landfill/refinery/factory) (in Km) |
text |
|
|
106 |
[hazard_risk]
Show the field ONLY if:
[hazardous_site] = ''
|
Type/risk |
text |
|
|
107 |
[dist_flood_prone] |
River/Water Body (in Km) |
text |
|
|
108 |
[flood_risk]
Show the field ONLY if:
[dist_flood_prone] = ''
|
Risk of flooding |
dropdown |
|
|
109 |
[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 |
|
|
110 |
[village] |
Section Header: Proximity\ Hazardous Site
Village/ settlement
|
radio (Matrix - ranking)| 1 | >15 km | | 2 | 10-15 km | | 3 | 5-10 km | | 4 | 1-5 km | | 5 | < 1 km |
|
|
|
111 |
[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 |
|
|
|
112 |
[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 |
|
|
|
113 |
[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 |
|
|
|
114 |
[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 |
|
|
|
115 |
[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 |
|
|
|
116 |
[building_characterstics] |
Section Header: SECTION D: PHYSICAL INFRASTRUCTURE & BUILDING SAFETY
Building Characteristics
|
descriptive |
|
|
117 |
[construction_year] |
Year of Construction |
text |
|
|
118 |
[structure_assessment] |
Structural assessment |
text |
|
|
119 |
[maintenance_structure] |
Last Maintenance |
text (date_dmy), Required |
|
|
120 |
[damage_type] |
Type of Damage |
text |
|
|
121 |
[repair_duration] |
Duration of Repair |
text |
|
|
122 |
[age] |
Section Header: building_score
Age of Building
|
radio (Matrix - ranking) |
|
|
123 |
[quality] |
Construction Quality |
radio (Matrix - ranking) |
|
|
124 |
[maintainence] |
Maintenance & Retrofitting |
radio (Matrix - ranking) |
|
|
125 |
[past_damage] |
Past Damage from Disasters |
radio (Matrix - ranking) |
|
|
126 |
[post_repair] |
Post-Disaster Repair |
radio (Matrix - ranking) |
|
|
127 |
[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 |
|
|
128 |
[evacuation_safety] |
D.2 Evacuation & Safety Routes |
descriptive |
|
|
129 |
[routes] |
Evacuation Routes |
radio (Matrix - ranking) |
|
|
130 |
[assemble] |
Evacuation Assembly Points |
radio (Matrix - ranking) |
|
|
131 |
[signage] |
Exit Signage & Lighting |
radio (Matrix - ranking) |
|
|
132 |
[triage] |
Triage/Decontamination Areas |
radio (Matrix - ranking) |
|
|
133 |
[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 |
|
|
134 |
[places_of_assembly_points] |
Places of Assembly points |
text |
|
|
135 |
[emergency_exit] |
Number of exits |
text |
|
|
136 |
[assembly_capacity] |
Capacity (in Numbers) |
text |
|
|
137 |
[emergcy_lights] |
Emergency Lightning |
dropdown |
|
|
138 |
[lift] |
Lift |
dropdown |
|
|
139 |
[ramp] |
Ramp |
dropdown |
|
|
140 |
[tactile_path] |
Tactile Path |
dropdown |
|
|
141 |
[location_triage] |
Location of safe area for triage Development |
text |
|
|
142 |
[hospital_capacity] |
D.3 Hospital Capacity & Surge Capacity |
descriptive |
|
|
143 |
[gen_bed]
Show the field ONLY if:
[fac_services(1)] = '1'
|
Section Header: General Medicine
Number of Beds
|
text |
|
|
144 |
[gen_expansion]
Show the field ONLY if:
[fac_services(1)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
145 |
[gen_infra]
Show the field ONLY if:
[fac_services(1)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
146 |
[surg_bed]
Show the field ONLY if:
[fac_services(2)] = '1'
|
Section Header: Surgery
Normal Beds
|
text |
|
|
147 |
[surg_expansion]
Show the field ONLY if:
[fac_services(2)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
148 |
[surg_infra]
Show the field ONLY if:
[fac_services(2)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
149 |
[pedia_beds]
Show the field ONLY if:
[fac_services(3)] = '1'
|
Section Header: Pediatrics
Normal Beds
|
text |
|
|
150 |
[pedia_expansion]
Show the field ONLY if:
[fac_services(3)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
151 |
[pedia_infra]
Show the field ONLY if:
[fac_services(3)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
152 |
[icu_beds]
Show the field ONLY if:
[fac_services(4)] = '1'
|
Section Header: ICU/HDU
Normal Beds
|
text |
|
|
153 |
[icu_expansion]
Show the field ONLY if:
[fac_services(4)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
154 |
[icu_infra]
Show the field ONLY if:
[fac_services(4)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
155 |
[emergency_beds]
Show the field ONLY if:
[fac_services(5)] = '1'
|
Section Header: Emergency
Normal Beds
|
text |
|
|
156 |
[emergency_expansion]
Show the field ONLY if:
[fac_services(5)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
157 |
[emergency_infra]
Show the field ONLY if:
[fac_services(5)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
158 |
[ot_beds]
Show the field ONLY if:
[fac_services(6)] = '1'
|
Section Header: Operating Theater
Normal Beds
|
text |
|
|
159 |
[ot_expansion]
Show the field ONLY if:
[fac_services(6)] = '1'
|
Expansion Capacity (beds/areas |
text |
|
|
160 |
[ot_infra]
Show the field ONLY if:
[fac_services(6)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
161 |
[isolation_bed]
Show the field ONLY if:
[fac_services(7)] = '1'
|
Section Header: Isolation/Quarantine
Normal Beds
|
text |
|
|
162 |
[isolation_expansion]
Show the field ONLY if:
[fac_services(7)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
163 |
[isolation_infra]
Show the field ONLY if:
[fac_services(7)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
164 |
[others_capacity]
Show the field ONLY if:
[fac_services(8)] = '1'
|
Other (specify) |
text |
|
|
165 |
[other_beds]
Show the field ONLY if:
[fac_services(8)] = '1'
|
Normal Beds |
text |
|
|
166 |
[other_expansion]
Show the field ONLY if:
[fac_services(8)] = '1'
|
Expansion Capacity (beds/areas) |
text |
|
|
167 |
[other_infra]
Show the field ONLY if:
[fac_services(8)] = '1'
|
Infrastructure for Surge (water, power, comms) |
text |
|
|
168 |
[surge_capacity] |
Hospital and surge capacity |
descriptive |
|
|
169 |
[emergency_space] |
Section Header: Additional Spaces for Emergency Use
(e.g., conference room, gymnasium, abandoned ward)
|
descriptive |
|
|
170 |
[emer_spaces] |
Space 1 |
text |
|
|
171 |
[emer_utilitity] |
Utilities (Water/Power/Phone) |
checkbox| 1 | emer_utilitity___1 | Water | | 2 | emer_utilitity___2 | Power | | 3 | emer_utilitity___3 | Phone |
|
|
|
172 |
[emer_area] |
Area (m²) |
text |
|
|
173 |
[emer_spaces2] |
Space 2 |
text |
|
|
174 |
[emer_utility] |
Utilities |
checkbox| 1 | emer_utility___1 | Water | | 2 | emer_utility___2 | Power | | 3 | emer_utility___3 | Phone |
|
|
|
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] |
Systems Tested |
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_sanitation_hygiene_w] |
Water, Sanitation & Hygiene (WASH)
1=Inadequate; 2=Poorly managed; 3=Moderately managed; 4=Well-managed, disrupted in disaster; 5=Resilient
Medical Waste Management
1=No system; 2=Poor (no segregation); 3=Moderate (partial segregation); 4=Good (segregation & pits); 5=Functional & resilient
Hazardous Material Handling
1=No checks; 2=Rare; 3=Monthly; 4=Weekly; 5=Daily
Vector Control
1=None; 2=Minimal; 3=Seasonal; 4=Regular; 5=Integrated program
Environmental Protection Practices
1=None; 2=Low; 3=Moderate; 4=High; 5=Comprehensive
Food Safety
1=Very low; 2=Low; 3=Moderate; 4=High; 5=Well-executed plan
|
descriptive |
|
|
229 |
[water_cap] |
Section Header: Water, Sanitation & Hygiene (WASH)
Toilet capacity
|
text |
|
|
230 |
[water_hand] |
Handwashing stations |
text |
|
|
231 |
[water_test] |
Water quality testing |
dropdown |
|
|
232 |
[waste_manage] |
Section Header: Medical Waste Management
3-bucket system
|
dropdown |
|
|
233 |
[waste_treat] |
Waste treatment |
text |
|
|
234 |
[hazard_handling] |
Section Header: Hazardous Material Handling
Chemical storage
|
text |
|
|
235 |
[vec_fre] |
Vector Control
Fogging/IRS frequency
|
text |
|
|
236 |
[envi_aware] |
Environmental Protection Practices
Awareness programs (Times/year)
|
text |
|
|
237 |
[food_pois] |
Food Safety
Food poisoning incidents
|
text |
|
|
238 |
[total_staff] |
Section Header: SECTION F: HUMAN RESOURCES & CAPACITY BUILDING
Total number of staff in the facility
|
text |
|
|
239 |
[staff_demo] |
F.1 Staffing & Demographics |
descriptive |
|
|
240 |
[staff_doc] |
Doctors |
descriptive |
|
|
241 |
[staff_doc_num] |
Numbers |
text |
|
|
242 |
[of_total_staff] |
% of Total Staff |
calc
Calculation: ([staff_doc_num]/[total_staff])*100 |
|
|
243 |
[staff_doc_status]
Show the field ONLY if:
[staff_doc_num] >0
|
Status |
descriptive |
|
|
244 |
[numbers_of_permanent]
Show the field ONLY if:
[staff_doc_num] >0
|
numbers of permanent |
text |
|
|
245 |
[numbers_of_contractual]
Show the field ONLY if:
[staff_doc_num] >0
|
numbers of contractual |
text |
|
|
246 |
[numbers_of_deputed]
Show the field ONLY if:
[staff_doc_num] >0
|
numbers of deputed |
text |
|
|
247 |
[of_permanents]
Show the field ONLY if:
[staff_doc_num] >0
|
permanent % |
calc
Calculation: round(([numbers_of_permanent]/[staff_doc_num])*100,2) |
|
|
248 |
[of_contractuals]
Show the field ONLY if:
[staff_doc_num] >0
|
contractual % |
calc
Calculation: round(([numbers_of_contractual]/[staff_doc_num])*100,2) |
|
|
249 |
[of_deputed]
Show the field ONLY if:
[staff_doc_num] >0
|
Deputed % |
calc
Calculation: round(([numbers_of_deputed]/[staff_doc_num])*100,2) |
|
|
250 |
[staff_doc_desi]
Show the field ONLY if:
[staff_doc_num] >0
|
Designation |
dropdown| 1 | Medical Officer | | 2 | Specialist |
|
|
|
251 |
[staff_doc_train]
Show the field ONLY if:
[staff_doc_num] >0
|
Disaster Training |
dropdown |
|
|
252 |
[staff_nurse] |
Nurses |
descriptive |
|
|
253 |
[staff_nurse_num] |
Numbers |
text |
|
|
254 |
[staff_nurse_per] |
% of Total Staff |
calc
Calculation: ([staff_nurse_num]/[total_staff])*100 |
|
|
255 |
[staff_nurse_status]
Show the field ONLY if:
[staff_nurse_num] >0
|
Status |
descriptive |
|
|
256 |
[permanent_nurse]
Show the field ONLY if:
[staff_nurse_num] >0
|
permanent nurse |
text |
|
|
257 |
[contractual_nurse]
Show the field ONLY if:
[staff_nurse_num] >0
|
contractual nurse |
text |
|
|
258 |
[deputed_nurse]
Show the field ONLY if:
[staff_nurse_num] >0
|
deputed nurse |
text |
|
|
259 |
[of_permanent]
Show the field ONLY if:
[staff_nurse_num] >0
|
% of Permanent |
calc
Calculation: round(([permanent_nurse]/[staff_nurse_num])*100,2) |
|
|
260 |
[of_contractual]
Show the field ONLY if:
[staff_nurse_num] >0
|
% of contractual |
calc
Calculation: round(([contractual_nurse]/[staff_nurse_num])*100,2) |
|
|
261 |
[of_deputed_nurse]
Show the field ONLY if:
[staff_nurse_num] >0
|
% of Deputed |
calc
Calculation: round(([deputed_nurse]/[staff_nurse_num])*100,2) |
|
|
262 |
[satff_nurse_desi]
Show the field ONLY if:
[staff_nurse_num] >0
|
Designation |
dropdown |
|
|
263 |
[staff_nurse_train]
Show the field ONLY if:
[staff_nurse_num] >0
|
Disaster Training |
dropdown |
|
|
264 |
[staff_paramed] |
Paramedics/Technicians |
descriptive |
|
|
265 |
[staff_paramed_num] |
Numbers |
text |
|
|
266 |
[staff_paramed_per] |
% of Total Staff |
calc
Calculation: ([staff_paramed_num]/[total_staff])*100 |
|
|
267 |
[staff_paramed_status]
Show the field ONLY if:
[staff_paramed_num] >0
|
Status |
descriptive |
|
|
268 |
[permanent_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
permanent paramed |
text |
|
|
269 |
[contractual_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
contractual paramed |
text |
|
|
270 |
[deputed_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
deputed paramed |
text |
|
|
271 |
[of_permanent_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
% of Permanent Paramed |
calc
Calculation: round(([permanent_paramed]/[staff_paramed_num])*100,2) |
|
|
272 |
[of_contractual_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
% of Contractual Paramed |
calc
Calculation: round(([contractual_paramed]/[staff_paramed_num])*100,2) |
|
|
273 |
[of_deputed_paramed]
Show the field ONLY if:
[staff_paramed_num] >0
|
% of Deputed Paramed |
calc
Calculation: round(([deputed_paramed]/[staff_paramed_num])*100,2) |
|
|
274 |
[staff_paramed_desi]
Show the field ONLY if:
[staff_paramed_num] >0
|
Designation |
dropdown |
|
|
275 |
[staff_paramed_train]
Show the field ONLY if:
[staff_paramed_num] >0
|
Disaster Training |
dropdown |
|
|
276 |
[staff_supp] |
Support Staff |
descriptive |
|
|
277 |
[staff_supp_num] |
Numbers |
text |
|
|
278 |
[staff_supp_per] |
% of Total Staff |
calc
Calculation: ([staff_supp_num]/[total_staff])*100 |
|
|
279 |
[staff_supp_status]
Show the field ONLY if:
[staff_supp_num] >0
|
Status |
descriptive |
|
|
280 |
[permanent_support_staff]
Show the field ONLY if:
[staff_supp_num] >0
|
permanent support staff |
text |
|
|
281 |
[contractual_support_staff]
Show the field ONLY if:
[staff_supp_num] >0
|
contractual support staff |
text |
|
|
282 |
[deputed_support_staff]
Show the field ONLY if:
[staff_supp_num] >0
|
deputed support staff |
text |
|
|
283 |
[of_permanent_support_staff]
Show the field ONLY if:
[staff_supp_num] >0
|
% of Permanent Support Staff |
calc
Calculation: round(([permanent_support_staff]/[staff_supp_num])*100,2) |
|
|
284 |
[of_contractual_support_sta]
Show the field ONLY if:
[staff_supp_num] >0
|
% of Contractual Support Staff |
calc
Calculation: round(([contractual_support_staff]/[staff_supp_num])*100,2) |
|
|
285 |
[of_deputed_support_staff]
Show the field ONLY if:
[staff_supp_num] >0
|
% of Deputed Support Staff |
calc
Calculation: round(([deputed_support_staff]/[staff_supp_num])*100,2) |
|
|
286 |
[staff_supp_desi]
Show the field ONLY if:
[staff_supp_num] >0
|
Designation |
dropdown |
|
|
287 |
[staff_supp_train]
Show the field ONLY if:
[staff_supp_num] >0
|
Disaster Training |
dropdown |
|
|
288 |
[staff_admin] |
Administrative Staff |
descriptive |
|
|
289 |
[staff_admin_num] |
Numbers |
text |
|
|
290 |
[staff_admin_per] |
% of Total Staff |
calc
Calculation: ([staff_admin_num]/[total_staff])*100 |
|
|
291 |
[staff_admin_status]
Show the field ONLY if:
[staff_admin_num] >0
|
Status |
descriptive |
|
|
292 |
[permanent_admin]
Show the field ONLY if:
[staff_admin_num] >0
|
permanent admin |
text |
|
|
293 |
[contractual_admin]
Show the field ONLY if:
[staff_admin_num] >0
|
contractual admin |
text |
|
|
294 |
[deputed_admin]
Show the field ONLY if:
[staff_admin_num] >0
|
deputed admin |
text |
|
|
295 |
[of_permanent_admin_staff]
Show the field ONLY if:
[staff_admin_num] >0
|
% of Permanent Admin Staff |
calc
Calculation: round(([permanent_admin]/[staff_admin_num])*100,2) |
|
|
296 |
[of_contractual_admin_staff]
Show the field ONLY if:
[staff_admin_num] >0
|
% of Contractual Admin Staff |
calc
Calculation: round(([contractual_admin]/[staff_admin_num])*100,2) |
|
|
297 |
[of_deputed_admin_staff]
Show the field ONLY if:
[staff_admin_num] >0
|
% of Deputed Admin Staff |
calc
Calculation: round(([deputed_admin]/[staff_admin_num])*100,2) |
|
|
298 |
[staff_admin_train]
Show the field ONLY if:
[staff_admin_num] >0
|
Disaster Training |
dropdown |
|
|
299 |
[staff_absent] |
Absenteeism during normal days in % |
text |
|
|
300 |
[staff_absebt_disaster] |
anticipated absenteeism during disaster in % |
text |
|
|
301 |
[indicator_1_20_2_40_3_50_4] |
Section Header: F.2 Disaster Awareness, Training and Drill
indicator 1= 20%, 2=40%, 3 =50%, 4=80%, 5=100%
|
descriptive |
|
|
302 |
[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% |
|
|
|
303 |
[disaster_knowledge_meth] |
Knowledge assessment method |
text |
|
|
304 |
[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 |
|
|
|
305 |
[disaster_train_date] |
Last training date |
text (date_dmy) |
|
|
306 |
[disaster_train_content] |
Training Content |
dropdown| 1 | CPR | | 2 | Fire Extinguisher | | 3 | Triage | | 4 | Evacuation | | 5 | Isolation | | 6 | Other |
|
|
|
307 |
[disaster_train_content_other]
Show the field ONLY if:
[disaster_train_content] = '6'
|
If Other |
text |
|
|
308 |
[disaster_train_participation] |
Training Participation |
dropdown| 1 | < 10% | | 2 | 11-25% | | 3 | 26-50% | | 4 | 51-75% | | 5 | 5=>75% |
|
|
|
309 |
[disaster_participant] |
Regular Participant |
text |
|
|
310 |
[disaster_drills] |
Disaster Preparedness Drills |
dropdown| 1 | None | | 2 | Rare | | 3 | Annual | | 4 | Biannual | | 5 | Quarterly |
|
|
|
311 |
[disaster_drills_date] |
Last Drill Date |
text (date_dmy) |
|
|
312 |
[disaster_disem] |
Disaster Plan Dissemination |
dropdown| 1 | None | | 2 | Low (some staff) | | 3 | Medium (most staff) | | 4 | High (all staff) | | 5 | Comprehensive (all + community) |
|
|
|
313 |
[disaster_disem_format] |
Format |
dropdown| 1 | IEC | | 2 | Manual | | 3 | Digital | | 4 | Verbal |
|
|
|
314 |
[type] |
Type |
checkbox| 1 | type___1 | Earthquake | | 2 | type___2 | Flood | | 3 | type___3 | Fire | | 4 | type___4 | MCI | | 5 | type___5 | Other |
|
|
|
315 |
[if_other_type]
Show the field ONLY if:
[type(5)] = '1'
|
if Other type |
text |
|
|
316 |
[drill_frequency] |
Drill frequency |
radio| 1 | None | | 2 | Rare | | 3 | Annual | | 4 | Biannual | | 5 | Quarterly |
|
|
|
317 |
[planned_schedule] |
Planned Schedule |
text |
|
|
318 |
[drill_duration_f2] |
Drill Duration |
text |
|
|
319 |
[real_time_exercise] |
Real Time Exercise |
dropdown |
|
|
320 |
[participants_f2] |
Participants |
checkbox| 1 | participants_f2___1 | Staff | | 2 | participants_f2___2 | Community | | 3 | participants_f2___3 | External agencies | | 4 | participants_f2___4 | Media |
|
|
|
321 |
[drill_attendance_in] |
Drill Attendance in % |
text |
|
|
322 |
[rate_how_many_issues_found] |
rate how many issues found during drills |
descriptive |
|
|
323 |
[manpower_staffing] |
Manpower/staffing |
radio (Matrix - ranking) |
|
|
324 |
[materials_supplies] |
Materials/supplies |
radio (Matrix - ranking) |
|
|
325 |
[training_gap] |
Training gaps |
radio (Matrix - ranking) |
|
|
326 |
[process_procedur] |
Process/procedure |
radio (Matrix - ranking) |
|
|
327 |
[procurement_issue] |
Procurement issues |
radio (Matrix - ranking) |
|
|
328 |
[debriefing_improvement] |
Debriefing & Improvement |
radio| 1 | 1=Not done | | 2 | 2=Informal | | 3 | 3=Documented | | 4 | 4=Action plan | | 5 | 5=Action plan implemented & monitored |
|
|
|
329 |
[minutes_available] |
Minutes Available |
dropdown |
|
|
330 |
[post_drill_report] |
Post Drill report |
dropdown |
|
|
331 |
[post_drill_date]
Show the field ONLY if:
[post_drill_report] = '1'
|
Date |
text (date_dmy) |
|
|
332 |
[disaster_preparedness] |
F.3 Disaster Preparedness Skills Assessment
For each skill, indicate % of staff trained (0-100%):1=< 20%, 2=21% to 40%, 3= 41% to 60%, 4= 61% to 80%, 5=>80%
|
descriptive |
|
|
333 |
[disaster_cpr] |
CPR/BLS |
text |
|
|
334 |
[disaster_cpr_train]
Show the field ONLY if:
[disaster_cpr] = ''
|
Last Training |
text (date_dmy) |
|
|
335 |
[disaster_cpr_cert]
Show the field ONLY if:
[disaster_cpr] = ''
|
Certification |
radio |
|
|
336 |
[disaster_cpr_course]
Show the field ONLY if:
[disaster_cpr] = ''
|
Course |
text |
|
|
337 |
[disaster_firstaid] |
First Aid |
text |
|
|
338 |
[disaster_first_train]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Last Training |
text (date_dmy) |
|
|
339 |
[disaster_first_cert]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Certification |
radio |
|
|
340 |
[disaster_first_course]
Show the field ONLY if:
[disaster_firstaid] = ''
|
Course |
text |
|
|
341 |
[disaster_safety] |
Fire Safety/Extinguisher Use |
text |
|
|
342 |
[disaster_safety_train]
Show the field ONLY if:
[disaster_safety] = ''
|
Last Training |
text (date_dmy) |
|
|
343 |
[disaster_safety_cert]
Show the field ONLY if:
[disaster_safety] = ''
|
Certification |
radio |
|
|
344 |
[disaster_safety_duration]
Show the field ONLY if:
[disaster_safety] = ''
|
Drills= Times/Year |
text |
|
|
345 |
[disaster_triage] |
Triage & Mass Casualty Management |
text |
|
|
346 |
[disaster_triage_train]
Show the field ONLY if:
[disaster_triage] = ''
|
Last Training |
text (date_dmy) |
|
|
347 |
[disaster_triage_cert]
Show the field ONLY if:
[disaster_triage] = ''
|
Certification |
radio |
|
|
348 |
[disaster_triage_protocol]
Show the field ONLY if:
[disaster_triage] = ''
|
Protocol |
text |
|
|
349 |
[disaster_infection] |
Isolation & Infection Control |
text |
|
|
350 |
[disaster_infection_train]
Show the field ONLY if:
[disaster_infection] = ''
|
Last Training |
text |
|
|
351 |
[disaster_infection_cert]
Show the field ONLY if:
[disaster_infection] = ''
|
Certification |
radio |
|
|
352 |
[disaster_infection_ppe]
Show the field ONLY if:
[disaster_infection] = ''
|
PPE Availability |
dropdown |
|
|
353 |
[disaster_haz] |
Hazmat/Chemical Decontamination |
text |
|
|
354 |
[disaster_haz_train]
Show the field ONLY if:
[disaster_haz] = ''
|
Last Training |
text (date_dmy) |
|
|
355 |
[disaster_haz_cert]
Show the field ONLY if:
[disaster_haz] = ''
|
Certification |
radio |
|
|
356 |
[disaster_haz_equip]
Show the field ONLY if:
[disaster_haz] = ''
|
Equipment |
text |
|
|
357 |
[disaster_psych] |
Psychosocial Support |
text |
|
|
358 |
[disaster_psych_train]
Show the field ONLY if:
[disaster_psych] = ''
|
Last Training |
text |
|
|
359 |
[disaster_psych_cert]
Show the field ONLY if:
[disaster_psych] = ''
|
Certification |
radio |
|
|
360 |
[disaster_psych_scope]
Show the field ONLY if:
[disaster_psych] = ''
|
Training scope |
text |
|
|
361 |
[disaster_swim] |
Swimming/Water Safety |
text |
|
|
362 |
[disaster_swim_train]
Show the field ONLY if:
[disaster_swim] = ''
|
Last Training |
text (date_dmy) |
|
|
363 |
[disaster_swim_cert]
Show the field ONLY if:
[disaster_swim] = ''
|
Certification |
radio |
|
|
364 |
[disaster_swim_flood]
Show the field ONLY if:
[disaster_swim] = ''
|
Relevance (flood-prone) |
radio |
|
|
365 |
[disaster_staff_incent] |
F.4 Staff Incentives & Motivation During Disasters |
descriptive |
|
|
366 |
[duty_incentive] |
Disaster Duty Incentives |
radio (Matrix - ranking) |
|
|
367 |
[leave_provision] |
Leave & Rest Provisions |
radio (Matrix - ranking) |
|
|
368 |
[psych_support] |
Psychological Support for Staff |
radio (Matrix - ranking) |
|
|
369 |
[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 |
|
|
370 |
[disaster_incent_policy] |
Policy |
text |
|
|
371 |
[disaster_duty_plan] |
Rotation Planned |
dropdown |
|
|
372 |
[disaster_staff_counsel] |
Counselor availability |
text |
|
|
373 |
[disaster_governance] |
Section Header: SECTION G: INSTITUTIONAL ARRANGEMENTS & ORGANIZATIONAL CAPACITY
G.1 Hospital Disaster Committee & Governance
|
text |
|
|
374 |
[disaster_esta] |
Formal Establishment |
dropdown |
|
|
375 |
[disaster_est_doc] |
Terms of reference document |
dropdown |
|
|
376 |
[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 |
|
|
|
377 |
[disaster_govern_cord] |
Designated Coordinator |
text |
|
|
378 |
[disaster_govern_profile] |
Job Profile |
dropdown |
|
|
379 |
[disaster_govern_dm_meet] |
Coordination with District DM Authority |
dropdown| 1 | None | | 2 | Poor | | 3 | Moderate | | 4 | Good | | 5 | Excellent |
|
|
|
380 |
[disaster_govern_dm_meet_freq] |
Meeting Frequency |
text |
|
|
381 |
[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 |
|
|
|
382 |
[disaster_govern_stake_freq] |
Meeting Frequency |
text |
|
|
383 |
[icc] |
G.2 Incident Command Centre (ICC) |
descriptive |
|
|
384 |
[space_design] |
Space Designation |
radio (Matrix - ranking) |
|
|
385 |
[physical_secure] |
Physical Security |
radio (Matrix - ranking) |
|
|
386 |
[comms_equipment] |
Communication Equipments |
radio (Matrix - ranking) |
|
|
387 |
[backup_light] |
Back Up Power and Lightning |
radio (Matrix - ranking) |
|
|
388 |
[computer_it] |
Computer system and Software |
radio (Matrix - ranking) |
|
|
389 |
[telephone_direct] |
Telephone Directory |
radio (Matrix - ranking) |
|
|
390 |
[supplies_furni] |
Supplies and Furniture |
radio (Matrix - ranking) |
|
|
391 |
[space_designation_1_not_as] |
Space Designation
1=Not assigned; 2=Assigned but not equipped; 3=Equipped; 4=Functional; 5=Fully operational with alternativesPhysical Security
1=Not safe; 2=Minimal; 3=Moderate; 4=Well-protected; 5=Safe, accessible, protected
Communications Equipment
1=Absent; 2=Incomplete; 3=Present; 4=Tested; 5=All systems functional
Backup Power & Lighting
1=None; 2=Limited; 3=Partial; 4=Good; 5=24-hour backup
Computer Systems & Software
1=None; 2=Basic; 3=Moderate; 4=Advanced; 5=Integrated management system
Telephone Directory
1=Absent; 2=Outdated; 3=Partial; 4=Complete; 5=Complete, current, verified
Supplies & Furniture
1=Minimal; 2=Partial; 3=Adequate; 4=Good; 5=Complete (desks, chairs, water, toilets)
|
descriptive |
|
|
392 |
[icc_space_location] |
Space Designation Location |
text |
|
|
393 |
[icc_security] |
Distance from main building |
text |
|
|
394 |
[icc_telephone] |
Telephone lines |
descriptive |
|
|
395 |
[icc_telephone_radio] |
2-way Radios |
dropdown |
|
|
396 |
[icc_telehone_net] |
Internet |
dropdown |
|
|
397 |
[icc_backup_ups] |
UPS backup in Hrs |
text |
|
|
398 |
[icc_computer_it_database] |
Patient Database backedup |
dropdown |
|
|
399 |
[icc_emergency_no] |
Emergency Number |
text |
|
|
400 |
[disaster_management_plan] |
G.3 Disaster Management Plans & Standard Operating Procedures |
descriptive |
|
|
401 |
[sops] |
SOPs & Protocols |
radio (Matrix - ranking) |
|
|
402 |
[disaster_codes] |
Disaster Codes (Color/Number System) |
radio (Matrix - ranking) |
|
|
403 |
[staff_action_card] |
Staff Action Cards |
radio (Matrix - ranking) |
|
|
404 |
[triage_protocol] |
Triage Protocol |
radio (Matrix - ranking) |
|
|
405 |
[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 |
|
|
406 |
[hdmp_status] |
Hospital Disaster Management Plan (HDMP) |
dropdown |
|
|
407 |
[hdmp_version] |
HDMP version date |
text (date_dmy) |
|
|
408 |
[idsdmp_status] |
Integration with District/State DM Plan |
dropdown |
|
|
409 |
[idsmp_alingmnet] |
Alingment |
text |
|
|
410 |
[sops_area] |
SOPS and Protocols Area covered |
text |
|
|
411 |
[color_code_definition] |
Disaster Codes (Color/Number System), Code definition |
text |
|
|
412 |
[actioncard_distribution] |
Staff Action Cards Distribution |
dropdown |
|
|
413 |
[supplylist_location] |
Pre-positioned Supplies List Location |
text |
|
|
414 |
[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 |
|
|
|
415 |
[mcmr] |
G.5 Mass Casualty Management Readiness |
descriptive |
|
|
416 |
[capacity_planing] |
Surge Capacity Planning |
radio (Matrix - ranking) |
|
|
417 |
[triage_areas] |
Triage Area Setup |
radio (Matrix - ranking) |
|
|
418 |
[casualty_flow] |
Casualty Management Flow |
radio (Matrix - ranking) |
|
|
419 |
[morgue_facility] |
Morgue/Mortuary Facilities |
radio (Matrix - ranking) |
|
|
420 |
[psycho_first_aids] |
Psychological First Aid for Victims |
radio (Matrix - ranking) |
|
|
421 |
[familt_comms_information] |
Family Support/Information System |
radio (Matrix - ranking) |
|
|
422 |
[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 |
|
|
423 |
[mass_surge_capacity_assum] |
Assumed Casualty Numbers |
text |
|
|
424 |
[triage_area] |
Triage Area setup Area size (m²) |
text |
|
|
425 |
[morgue_capacity] |
Morgue/Mortuary Facilities capacity |
text |
|
|
426 |
[psych_first_aid] |
Personnel trained Psychological First Aid for Victims |
text |
|
|
427 |
[family_communication] |
Family Support/Information System Communication method |
text |
|
|
428 |
[budget_allocation] |
Section Header: SECTION H: INSTITUTIONAL CONDITIONS & RESOURCES
H.1. What is the budget allocation across categories (e.g., preparedness planning, infrastructure maintenance, equipment supplies, recovery etc) for disaster management, tentative amount (as a percentage of the total budget).
|
notes |
|
|
429 |
[h_1_1_what_is_the_status_o] |
H.1.1. What is the status of this fund (whether spent or any plans being made)? |
notes |
|
|
430 |
[h_2_what_support_has_been] |
H.2. What support has been received from various sources (e.g., national government schemes, NGOs, private sector, community resources) for resource mobilization before, during and after a disaster event? |
notes |
|
|
431 |
[h_2_1_what_type_of_support] |
H.2.1. what type of support you get during previous event in terms of (funding/ technical/ donation/ volunteers grants etc)? |
notes |
|
|
432 |
[collaberation_freq] |
H.3. How frequent and of what quality is inter-agency collaboration (e.g., meetings with health officials, coordination with DM authority, liaison with police/fire department, engagement with NGOs? |
notes |
|
|
433 |
[comm_disa_aware] |
I.1 Community Disaster Awareness & Participation |
descriptive |
|
|
434 |
[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 |
|
|
435 |
[awareness_meeting_frequenc] |
Awareness Meeting Frequency |
radio |
|
|
436 |
[attendance] |
Attendance |
text |
|
|
437 |
[training_quality_for_commu] |
Training Quality for Community |
radio |
|
|
438 |
[participants] |
Participants |
text |
|
|
440 |
[activities] |
Activities |
text |
|
|
441 |
[plan_sharing_with_communit] |
Plan Sharing with Community |
radio |
|
|
442 |
[formats] |
Formats |
checkbox| 1 | formats___1 | Posters | | 2 | formats___2 | Flyers | | 3 | formats___3 | Videos | | 4 | formats___4 | Meetings |
|
|
|
443 |
[support_from_cbos_ngos] |
Support from CBOs/NGOs |
radio |
|
|
444 |
[organizations] |
Organizations |
text |
|
|
445 |
[i_2_early_warning_system_n] |
I.2 Early Warning System & Notification |
descriptive |
|
|
446 |
[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 |
|
|
447 |
[early_warning_reception_sy] |
Early Warning Reception System |
radio |
|
|
448 |
[source] |
Source: |
dropdown| 1 | District/State authority | | 2 | Meteorological |
|
|
|
449 |
[early_warning_disseminatio] |
Early Warning Dissemination |
radio |
|
|
451 |
[method] |
Method |
dropdown| 1 | SMS | | 2 | Call | | 3 | Siren | | 4 | Radio | | 5 | Other |
|
|
|
452 |
[if_other]
Show the field ONLY if:
[method] = '5'
|
if other |
text |
|
|
453 |
[ews_testing_drills] |
EWS Testing & Drills |
radio |
|
|
454 |
[if_ews_testing_and_drills] |
if EWS Testing and Drills |
dropdown |
|
|
455 |
[if_yes_frequency_year]
Show the field ONLY if:
[if_ews_testing_and_drills] = '1'
|
If yes (Frequency/Year) |
text |
|
|
456 |
[last_test_date] |
Last test Date |
text (date_dmy) |
|
|
457 |
[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 |
|
|
458 |
[is_there_any_other_facilit] |
Is there a provision of operating alternate facilities in case of damage to the healthcare building during a disaster? |
notes |
|
|
459 |
[what_of_staff_is_deployed] |
what % of staff is deployed to relief camps in case of floods/disasters from your facility? |
notes |
|
|
460 |
[does_your_facility_get_any] |
Does your facility get any funding through awards like Kayakalp, Swacch Swasthya etc? |
notes |
|
|
461 |
[general_observations_provi] |
Section Header: SECTION L: ASSESSOR NOTES & OBSERVATIONS
General Observations
Provide a narrative summary of key observations during the assessment
|
notes |
|
|
462 |
[challenges_encountered_dur] |
Challenges Encountered During Assessment |
notes |
|
|
463 |
[follow_up_actions_required] |
Follow-up Actions Required |
notes |
|
|
464 |
[facility_representative_co] |
Facility Representative Comments/Clarifications |
notes |
|
|
465 |
[name_designation] |
Section Header: SECTION M: ASSESSMENT COMPLETION CERTIFICATION
Name & DesignationAssessment Completed By:
|
text |
|
|
466 |
[signature] |
Signature |
file (signature) |
|
|
467 |
[assessment_date] |
Date |
text (date_dmy) |
|
|
468 |
[contact_phone] |
Contact Phone |
text |
|
|
469 |
[contact_email] |
Contact email |
text |
|
|
470 |
[name_and_designation] |
Section Header: Facility Representative/Authorized Signatory
Name and Designation
|
text |
|
|
471 |
[authorize_sign] |
Authorize Sign |
file (signature) |
|
|
472 |
[auth_date] |
Date |
text (date_dmy) |
|
|
473 |
[witness_name_and_designation] |
Name And Designation |
text |
|
|
474 |
[witness_signature] |
Witness Signature |
file (signature) |
|
|
475 |
[witness_dates] |
Witness Date |
text (date_dmy) |
|
|
476 |
[hdraform_complete] |
Section Header: Form Status
Complete?
|
dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
|
|
|
477 |
[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 |
|
|
478 |
[information_sheet_complete] |
Section Header: Form Status
Complete?
|
dropdown| 0 | Incomplete | | 1 | Unverified | | 2 | Complete |
|
Add users
Remove users
Download as Excel/CSV
Archive conversation
