Page 54 - 372.w

Appendix F:

Data Collection and Evaluation Forms

Purpose
These sample forms can be used to collect the data required to evaluate the exercise and to
create an improvement plan.

How to Use These Forms

1. Data Collector Observation Log
Used to collect the observations in the field Step 2. Data collector fills out the date of
during the exercise. Player action is observed. the exercise, the time he/she started
The data collector determines if the criteria observing, and the time he/she stopped
selected by the planning team were met or observing.
not met, not observed, or not applicable
during their observation. Observation meth- Step 3.The list of criteria and expected
actions is periodically reviewed and
ods are Look, Listen, and Ask (but do not
checked as completed, met, not met, not
interfere with operations being conducted
during the exercise). Data collectors record observed, or not applicable.
when, where, and what is happening. Step 4.The last page of the evaluation
form is used for comments or to docu-
Step 1. Data collector fills out his/her
name and contact information (important ment specific observations about prob-
if he/she must be contacted for clarifica- lems encountered by the exercise partici-
pants and suggestions or solutions for
tion).The planning team should complete
improvement.
both the location/site (where the data
collector is assigned) and LPHA contact
information in advance.

2. Role Evaluation Checklist
Used by the data collector or evaluator to doc-
ument their observations during the exercise.

3. Station-Specific Throughput Timesheet
For use at a Mass Care or Point of station. It helps to determine if there are
Distribution (POD) Exercise.The sheet is problems related to moving patients through
utilized at each station to note the time of the established mass care facility or POD.
arrival and departure from that particular

4. Actor-Specific Throughput Timesheet

Intended for use at a Mass Care or POD the time required for a “patient” to travel
Exercise.The sheet is carried by each patient through the site, if he/she was directed prop-
actor to note the time of arrival and depar- erly, and helps to gauge site capacity.
ture as they travel from station to station in
the mass care facility or POD. It documents

52