Hospital Readiness Assessment Form
Use this form to assess how prepared a hospital is across key operational, clinical, and support areas.
Hospital Profile
Hospital Name
*
Department / Unit Being Assessed
*
Please Select
Emergency Department
Inpatient Ward
Outpatient Clinic
Intensive Care Unit
Operating Room
Laboratory
Pharmacy
Other
Facility Type
*
General Hospital
Specialty Hospital
Clinic
Emergency Unit
Other
Location / City
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Operational Readiness
Staffing adequacy
*
Very inadequate
1
2
3
4
5
6
7
8
9
Fully adequate
10
1 is Very inadequate, 10 is Fully adequate
Available beds/spaces
*
Patient intake and throughput readiness
*
1
2
3
4
5
Availability of essential equipment
*
Rows
Available
Limited
Unavailable
Monitoring equipment
1
2
3
Oxygen supply equipment
4
5
6
Ventilators
7
8
9
Infusion pumps
10
11
12
Emergency carts
13
14
15
Supplies, Safety, and Clinical Support
Availability of Critical Supplies
*
Rows
Adequate
Partially Adequate
Limited
Unavailable
PPE
16
17
18
19
IV supplies
20
21
22
23
Oxygen delivery supplies
24
25
26
27
Sterile dressing supplies
28
29
30
31
Basic diagnostic supplies
32
33
34
35
Infection Control Preparedness
*
Not Prepared
1
2
3
4
5
6
7
8
9
Fully Prepared
10
1 is Not Prepared, 10 is Fully Prepared
Emergency Response Readiness
*
Adequate
Partially adequate
Limited
Unavailable
Medication and Supply Stock Status
*
Please Select
Adequate
Partially adequate
Limited
Unavailable
Immediate Shortages or Gaps
Systems, Training, and Follow-up
EMR / Records System Readiness
*
Fully ready
Partially ready
Not ready
Not applicable
Staff Training Completion Status
*
Completed
In progress
Not started
Needs refresher
Current Protocols and Guidelines Available
*
Complete and current
Partially available
Outdated
Not available
Top Priority Actions Needed Before Operations or Review
Complete staff training
Update protocols and guidelines
Finalize documentation system
Address equipment gaps
Improve workflow coordination
Other
Assessor Comments / Recommendations
Submit Assessment
Should be Empty: