Page 58 - 372.w

Appendix F:

2. Role Evaluation Checklist

Sample Role Evaluation Checklist

Role Evaluation Checklist
Role Being Evaluated: Clinic Manager (Exercise Scenario-FLU)
Incident: Mass prophylaxis point of distribution (POD)
Outcome: Protection Location:Anytown High School
Response Element: PH staff and volunteers Jurisdiction:Anytown Municipal District
Evaluator: John Smith LPHA Contact:Site Commander
Date of Exercise:4/14/06 Start Time: 8:00 AM End Time: 4:00 PM

Part I. For each criterion, check the appropriate column and add comments as appropriate.
LPHA Criteria Met Not Not N/A Comments/
Met Observed Recommendations
1. Generic mass-dispensing strategy X Exceeded limit within
adapted to specific event within 60 “exercise time frame”
minutes of notification.
2. Dispensing site(s) staffed with ade- X
quate and appropriate personnel for
mass dispensing (including volunteer
surge staff) prior to site opening time.
3. Just-in-time training (including X Took more than time
use of PPE) identified and requested allotted
at least 2 hours prior to site opening.
4. System in place to restock sup- X Restocking delayed due
plies throughout duration of site to transport not able to
activation. get through
5. System in place to rotate or X
relieve staff throughout duration of
site activation.
6. All required record-keeping sup- X
plies prepared and delivered to site
coordinator prior to site opening.

56