DRAFT

Part 1: Hospital Diesel Generator Survey

Person who is completing the form:
Name: _______________________________________________________________________________
Title: ________________________________________________________________________________
Hospital Name: _______________________________________________________________________
Phone: ______________________________________________________________________________
Email: _______________________________________________________________________________
Address:_____________________________________________________________________________
City: _________________________________________________ State: _____ Zip Code: __________
County:______________________________________________________________________________
If part of a health system, please provide system name: ________________________________________

1. Number of Licensed General Acute Care Inpatient Beds? ___________ beds

2. Number of Intensive Care Beds? ___________ beds
3. How many surgical suites do you have? ___________ surgical suites
4. Do you have an emergency department?

___ Yes

___ No

a. If yes, is it:
i. ____ Standby
ii. ____ Basic
iii. ____ Comprehensive
b. If yes, are you a designated trauma center?

___ Yes

___ No

5. If power to the hospital is curtailed, approximately what percent of the following services would
be available through the use of diesel backup generators?
a.
b.
c.
d.

Acute Care Beds:

Intensive Care Beds:
Surgical Suites:
Emergency Department Services:

_______%
_______%
_______%
_______%

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April 2013

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6. What percent of the following beds/services in your hospital are in OSHPD Structural
Performance Category 1 (SPC-1) buildings and SPC-2 buildings?
a.
b.
c.
d.

General Acute Care Beds:

Intensive Care Beds:
Surgical Suites:
Emergency Room Services:

SPC-1
_______%
_______%
_______%
_______%

SPC-2
_______%
_______%
_______%
_______%

7. How many stationary backup generators does your hospital have?

______________________________________________________________________________
a. For each of your stationary generators, please provide the following information:
i. Manufacturer of generator
_____________________________________________
ii. Approximate age of generator in years
___________________________________
iii. Basic and critical services areas served by the
generator______________________
__________________________________________________________________
iv. Output in Kw
_______________________________________________________
v. Fuel type (gasoline, diesel, natural gas) __________________________________
vi. Fuel storage capacity (gallons) _________________________________________
vii. Fuel consumption rate at full load (gal/hr) ________________________________
8. How many gallons of fuel do you have stored on site? ___________ gallons
9. Do you have a contract for a backup generator fuel source?

___ Yes

10. Are all your generators above flood plain?

___ No

11. Is your fuel tank(s) above flood plain?

___ Yes
___ Yes

___ No

___ No

a. If no, is it encapsulated and protected from a flood?

___ Yes
___ No
12. Who is your primary electrical utility provider? ________________________________________
13. Did your facility lose power from your electrical utility provider during the past 24 months?
___ Yes
___ No
a. If yes, what was the longest duration of time? ___________________________________
14. If your facility did lose power from your electrical utility provider, did your generators start
automatically and transfer all required loads to the generator within ten seconds?

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______________________________________________________________________________
15. Did your facility have any system or equipment failures as a result of one or more running backup
generators starting, but turning off, before utility power returned?
___ Yes
___ No
a. If yes, please explain:
_______________________________________________________________________
_______________________________________________________________________
__
16. If you did experience a backup generator failure, what basic and critical services were affected?
______________________________________________________________________________
17. Did you have adequate fuel on-site for the generators?

___ Yes

___ No

a. If no, please explain:

_______________________________________________________________________
_______________________________________________________________________
__
18. If you required additional fuel, were you able to access it?

___ Yes

___ No

a. If yes, from what source? ___________________________________________________

19. Who would you contact to assist you in providing additional/replacement backup generators
and/or fuel when power is not available?
______________________________________________________________________________
20. Is the heating/cooling system connected to the stationary back-up generators?
___ Yes
___ No
___ Unknown
21. Do all stationary back-up generators have a direct line to on site fuel storage?
___ Yes
___ No
___ Unknown
22. Do you possess smaller generators for use in surge tents or other treatment areas?
___ Yes
___ No

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April 2013
___ Unknown

Page 4

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Part 2: Hospital Water Survey

1. What is the approximate gallons of:
a. Potable water per day used in your hospital? ___________ gallons
b. Non-potable water per day used in your hospital? ___________ gallons
2. Do you have a water conservation/rationing plan in case of a utility failure?
___ Yes
___ No
a. If yes, what is approximate gallons of:
i. Potable water per day used in your hospital? ___________ gallons
ii. Non-potable water per day used in your hospital? ___________ gallons
3. Is there a backup service of potable water on site?

___ Yes

___ No

a. If yes, what is the source?

i. Holding Tank

___ Yes

___ No

1. If yes, how approximate number of gallons the tank holds?

_________ gallons
ii. Bottled Water

___ Yes

___ No

1. If yes, approximately how many gallons on site?

_________ gallons of bottled water
iii. Do you have a well on site?
iv. Other sources on site?

___ Yes
___ Yes

___ No
___ No

1. If yes, please explain: __________________________________

4. Is there a backup service of non-potable water on site?

___ Yes

___ No

a. If yes, what is the service?

i. Holding Tank

___ Yes

___ No

1. If yes, how approximate number of gallons the tank holds?

_________ gallons
ii. Do you have a well on site?

___ Yes

___ No

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iii. Other sources of non-potable water:

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
5. Do you have a holding tank for waste if toilets do not work?

___ Yes

___ No

a. If yes, what size tank? ___________________ gallons

6. Do you have a plan for water rationing if there is a water disruption?
___ Yes
___ No
___ In Process
___ Unknown
7. If your facility does have a water hook up, has it been tested for compatibility with the delivery
truck?
___ Yes
___ No
___ In Process
___ Unknown
a. If yes, what is the source from which water is obtained?
_______________________________________________________________________
_______________________________________________________________________
__
8. Do you have a tank into which a water delivery truck can empty water?
___ Yes
___ No
a. If yes, approximately how large is the tank? _____________ gallons
9. Do you have the ability to pressurize an external water source to pump water from storage into
your facility?
___ Yes
___ No
___ In Process
___ Unknown

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Part 3: Other
1. Does your facility have a designated landing zone for helicopters?
___ Yes
___ No
a. If yes,
ii. What is the weight capacity?
___________________________________________
iii. What aircraft are rated for this landing zone?
______________________________
iv. Is the landing zone at ground level?
_____________________________________
b. If no,
v. Is there an alternate location nearby for helicopter landing?
vi. Describe:
_________________________________________________________________
_________________________________________________________________