Form 0285 emergency pre 0285 emergency pre 0285 emergency preparedness

OMB No. 0915-0285

Expiration Date:

EMERGENCY PREPAREDNESS FORM

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection

of information unless it displays a currently valid OMB control number. The OMB control number for this

project is 0915-0285. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the

collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

SECTION I - EMERGENCY PREPAREDNESS AND MANAGEMENT PLAN	YES	NO
Has your organization conducted a thorough Hazards Vulnerability Assessment? If yes, the date completed:______
Does your organization have a written EPM plan? If Yes, the date most recent EPM plan was approved by your Board:_________________ If No, skip to Readiness section below. Date
Does the EPM plan specifically address the four disaster phases? Mitigation? Preparedness? Response? Recovery?
Is your EPM plan integrated into your local/regional emergency plan?
If no, has your organization attempted to participate with local/regional emergency planners?
Does the EPM plan address your capacity to render mass immunization/prophylaxis?
SECTION II - READINESS	YES	NO
Does your organization include alternatives for providing primary care to your current patient population if you are unable to do so during an emergency?
Does your organization conduct annual planned drills?
Does your organization’s staff receive periodic training on disaster preparedness?
Will the organization be required to deploy staff to non-Health Center sites/locations according to the emergency preparedness plan for the local community?
Does your organization have arrangements with Federal, State, and/or local agencies for reporting of data?
Does your organization have a back-up communication system? Internal? External?
Does your organization coordinate with other systems of care to provide an integrated emergency response?
Has your organization been designated to serve as a point of distribution (POD) for providing antibiotics, vaccines, and medical supplies?
Has your organization implemented measures to prevent financial/revenue and facilities loss due to an emergency? (e.g. insurance coverage for short-term closure)
Does your organization have an off-site back up of your information technology system?
Does your organization have a designated EPM coordinator?