Evaluation Record of Response Actions Testing

[Organization/Agency Name]
[Date of Evaluation]
[Location of Evaluation]

I. General Information:
1. Evaluation Date: __________________
2. Location of Evaluation: __________________
3. Evaluation Team Members:
- Name: ______________________
Title: ______________________
- Name: ______________________
Title: ______________________
- Name: ______________________
Title: ______________________
- Name: ______________________
Title: ______________________

II. Scenario Overview:

1. Scenario Description:
- Nature of Emergency: __________________
- Date and Time: __________________
- Details: ____________________________

2. Response Plan:
- Summary of the Emergency Response Plan: ___________________________
- Responsible Parties: ___________________________________________

III. Response Actions Evaluation:

1. Activation and Notification:
- Was the emergency response plan activated promptly? ☐ Yes ☐ No
- Were notifications to relevant parties effective and timely? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

2. Scene Assessment:
- Were responders able to accurately assess the emergency situation? ☐ Yes
☐ No
- Were hazards identified and communicated? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________
3. Resource Mobilization:
- Were resources (personnel, equipment) deployed according to the plan? ☐ Yes
☐ No
- Was there any resource shortage or surplus? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

4. Incident Command:
- Was an incident command structure established and maintained? ☐ Yes ☐ No
- Was the incident commander effective in managing the response? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

5. Communications:
- Was communication effective and reliable within the response team? ☐ Yes
☐ No
- Were communication procedures followed? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

6. Actions and Mitigation:

- Were response actions aligned with the emergency plan and goals? ☐ Yes ☐ No
- Were mitigation measures implemented effectively? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

7. Evacuation (if applicable):

- Was the evacuation process well-organized and safe? ☐ Yes ☐ No
- Were evacuation routes clear and well-marked? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

8. Medical Response (if applicable):

- Was medical aid provided promptly and effectively? ☐ Yes ☐ No
- Were medical resources adequate for the situation? ☐ Yes ☐ No
- Comments/Feedback: ___________________________________________

IV. Evaluation Summary:

1. Overall Assessment of the Response: ☐ Effective ☐ Partially Effective ☐
Ineffective
2. Key Strengths of the Response:
- ________________________________________________________________
- ________________________________________________________________
3. Areas for Improvement:
- ________________________________________________________________
- ________________________________________________________________

4. Recommendations for Future Response:

- ________________________________________________________________
- ________________________________________________________________

V. Action Plan:
1. Based on the evaluation, outline specific actions and recommendations for
improving future emergency responses.

- Action Item 1:
- Responsible Party: ______________________
- Deadline: _____________________________
- Description: ___________________________

- Action Item 2:
- Responsible Party: ______________________
- Deadline: _____________________________
- Description: ___________________________

VI. Sign-off:
I hereby certify that this Emergency Response Evaluation Record accurately reflects
the evaluation conducted on [Date]. The information contained in this report is
complete and accurate to the best of my knowledge.

Evaluator's Name: ______________________________

Title: ______________________________
Signature: ______________________________
Date: ______________________________

[Additional Signatures and Comments if needed]

Please note that this template is a starting point, and you should tailor it to the
specific needs and requirements of your organization and the nature of the
emergency response scenarios you are evaluating.