Hospital Emergency Department Staff Survey
Preparedness for WIPP Transportation Incidents
6/99

Date: ________ Hospital Name: _____________________________
County: __________________

About You:

(Optional) Your Name: _________________________________

Check your training / staff level (check all that apply): ___ Emergency Room Physician;
___ Emergency Department Staff; ___ PA; ___ RN; ___LPN; ___ ER Tech;
___ Respiratory Therapist; ___ EMT; ___ Radiology Tech; ___ Radiation Safety Officer
___ Other - please describe_______________

Job Title:

___________________________________________________

About Your Training:

1.Have you attended training that included information about WIPP transportation?
___ Yes ___ No

2.Did you know that the State of New Mexico sponsors WIPP medical response training at no cost? ___ Yes ___ No

3.Have you attended training that included information about the medical treatment of WIPP accident victims? ___ Yes ___ No

4.If yes, please list the course title(s) and approximate date(s) that you attended:

____________________________________________________________ __

____________________________________________________________ __

5.Did you participate in a drill or exercise as a part of the training? ___ Yes ___ No

6.Do you understand your role in a hazardous materials incident? ___ Yes ___ No

7.Do you feel adequately trained to safely handle a radioactively contaminated patient? ___ Yes ___ No

8.If no, what do you think you need to feel adequately trained to handle a radioactively contaminated patient? ____ more training ____ equipment ____ policy/procedure

Please list specific needs:

____________________________________________________________ ___

____________________________________________________________ ___

9.Do you want to know the schedule of WIPP shipments? ___ Yes ___ No

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

11.Would you personally respond to a radioactive materials incident? ___ Yes ___ No

12.Would you personally respond to a hazardous materials incident? ___ Yes ___ No

About your hospital:

13.Do you think that your department/agency has the equipment (including radiation detection equipment) it needs to perform the skills necessary for radioactive / hazardous materials response? ___ Yes ___ No

14.If no, please list the equipment that you think your department or agency needs to respond to a radioactive / hazardous materials incident (be specific).

____________________________________________________________ ___

____________________________________________________________ ___

15.If you answered yes, can you access the radiation detection equipment? ___ Yes ___ No

16.Who do you think is responsible for cleaning or replacing contaminated department / agency equipment?

____________________________________________________________ ___

17.Who do you think is responsible for cleaning / replacing personal equipment that may become contaminated responding to a radioactive / hazardous materials incident?

____________________________________________________________ ___

About Your Community:

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

19.If yes, do you understand your role in the all hazards plan? ____ Yes ___ No

Comments (use additional pages if needed):

____________________________________________________________ ___

____________________________________________________________ ___

____________________________________________________________ ___

Please return this survey to:
Ralph Davis
WIPP Medical Preparedness Coordinator
Injury Prevention and EMS Bureau
New Mexico Dept. of Health
P.O. Box 26110
Santa Fe, New Mexico 87502
Telephone: 505-476-7000 ex. 123
Fax: 505-476-7010
Email: ralphd@doh.state.nm.us

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