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SDHCC 2023 Statewide Exercise - Facility Participation Survey
Facility Demographics
Note that this is a two page survey. please click next at the bottom of this page to answer participation questions.
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1.
Contact Name
(Required.)
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2.
Facility Name
(Required.)
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3.
Facility Address
(Required.)
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4.
Email
(Required.)
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5.
Please define your facility type: If you provide more than one service, choose all that apply
(Required.)
Medical Center
Regional Hospital
Critical Access Hospital
Skilled Nursing Facility
Assisted Living Facility
Senior Living Facility
Rural Health Clinic
Dialysis Center
Behavioral Health Facility
Specialty Hospital
EMS Agency
Emergency Management Agency
State DOH
Other (please specify)
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6.
Facility Chapter
(Required.)
Black Hills
Glacial Lakes
Sioux Empire
South Central
I am not sure
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7.
Our facility will participate in this exercise
(Required.)
Yes
No
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8.
Our facility has a command center
(Required.)
Yes
No
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9.
Our facility has access to the SDHCC eICS Command tool
(Required.)
Yes
No
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10.
Our facility has been trained in Incident Command
(Required.)
Yes
No
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11.
Our facility has participated in at least one previous SDHCC Statewide Exercise
(Required.)
Yes
No
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12.
This exercise will give facilities the opportunity to test their internal plans. A facility can choose to be either an affected facility, where decision making would involve protecting in place or evacuation/ relocation capabilities, OR, being a receiving facility where decision making would include increasing capacity to receive evacuated patients. Please choose which tasks you would like your facility to work through during the exercise. (Note that all task sheets will be made available after the exercise). Please be advised that we will try to accommodate your first choice. We need approximately 10 facilities to evacuate.
(Required.)
We would like to work through the evacuation scenario
We would like to work through the surge capacity scenario
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13.
A pre-event briefing will be held on 10/12 at 10AM CT. This briefing will outline the exercise and expectations. This brief will be very helpful to new partner facilities.
Our facility will attend the pre-event breifing on 10/12 at 10AM
(Required.)
Yes
No
