Healthcare Coalition Questionnaire

Coalition Questionnaire

As the designated representative for your coalition, we appreciate your completing the following questionnaire. In order to get accurate data, we 
ask that you answer all questions completely and honestly. You will be provided a summary of your answers. These questions will take 
approximately 30­60 minutes to complete. 

*1. As the designated representative for your coalition, we appreciate your completing

the following questionnaire. In order to get accurate data, we ask that you answer all
questions completely and honestly. You will be provided a summary of your answers.
these questions will take approximately 30­45 minutes to complete.
Coalition Name
URL: (if available)
Address:
Address 2:
City/Town:
State:

6

ZIP:
Point of Contact:
Email Address:
Phone Number:

*2. When was your coalition established?
MM
MM/DD/YYYY

DD
/

YYYY
/

*3. Please describe why the coalition was initially formed. (100 word limit)
5
6  

*4. What is the primary population base that this coalition serves? (Check all that apply)
j Rural
k
l
m
n

j Urbanized Area (over 50,000)
k
l
m
n

j Urbanized Clusters (2,500­49,999)
k
l
m
n

Other (e.g. Frontier) 

*5. How many counties/ parishes does your coalition represent?

Page 1

Coalition Questionnaire

*6. Does your coalition include tribal areas?

j Yes
k
l
m
n
j No
k
l
m
n

*7. How many tribal areas does your coalition represent?
Number of Tribal Areas

*8. Does your membership cross state boundaries

j Yes
k
l
m
n
j No
k
l
m
n

*9. Please name the border states.
State 1
State 2
State 3
State 4
State 5

*10. Please select the choice that best describes the basis for the boundary that the

coalition serves. (Select one)

j Functional Service Region (i.e. Trauma, Public Health, 
k
l
m
n
Coordinating Hospital, Emergency Medical Services (EMS) or Health 
Catchment Area) 

j Hazard Vulnerability Assessment (HVA)
k
l
m
n

j Other pre­identified region
k
l
m
n
j No function/service region
k
l
m
n

j Geographic Areas Represented by Zip Codes (County, 
k
l
m
n
City/Town) 

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Coalition Questionnaire

*11. Please identify the name and type of organizations that are represented within the

coalition. (List the names of the organizational members and select the type of
organization they represent)
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8
Member 9
Member 10
Member 11
Member 12
Member 13
Member 14
Member 15
Member 16
Member 17
Member 18
Member 19
Member 20
Member 21
Member 22
Member 23
Member 24
Member 25
Member 26
Member 27
Member 28
Member 29
Member 30
Member 31
Member 32

Page 3

Coalition Questionnaire
Member 33
Member 34
Member 35
Member 36
Member 37
Member 38
Member 39
Member 40
Member 41
Member 42
Member 43
Member 44
Member 45
Member 46
Member 47
Member 48
Member 49
Member 50
Member 51
Member 52
Member 53
Member 54
Member 55
Member 56
Member 57
Member 58
Member 59
Member 60
Member 61
Member 62
Member 63
Member 64
Member 65
Member 66
Member 67

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Coalition Questionnaire
Member 68
Member 69
Member 70
Member 71
Member 72
Member 73
Member 74
Member 75
Member 76
Member 77
Member 78
Member 79
Member 80
Member 81
Member 82
Member 83
Member 84
Member 85
Member 86
Member 87
Member 88
Member 89
Member 90
Member 91
Member 92
Member 93
Member 94
Member 95
Member 96
Member 97
Member 98
Member 99
Member 100

Page 5

Coalition Questionnaire

*12. Based on the list in Question 11, how many organizations provide financial

resources to support the coalition activities? Enter Number (Criteria: Not Exceed Number
on Questions 11)

*13. Please select the option below that best describes the status of your mission and

vision statement. (Select One)

j Mission and vision statement has been developed, approved, and published
k
l
m
n
j Mission and vision statement has been developed, but not approved
k
l
m
n
j Neither (No missionor vision statement has been developed)
k
l
m
n

j Unsure
k
l
m
n

*14. Does a 3­5 year strategic plan exist?

j Yes
k
l
m
n
j No
k
l
m
n

*15. Are most (at least 75%) or all objectives specific, measurable, attainable, relevant,

and timely (SMART)?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

*16. If no, are you planning on developing a comprehensive strategic plan?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

Page 6

Coalition Questionnaire

*17. When is the expected completion date of the comprehensive strategic plan?
MM
Expected Completion 

DD
/

YYYY
/

Date

*18. Please select the option below that best describes the type of agreement (e.g.,

memorandum of understanding (MOU), mutual aid agreement (MAA), or other compact
agreement) that has been established for public health emergencies or disasters (i.e.,
catastropic health events), if any. (Select One)
j Formal agreement (signed with responsibilities and expectations clearly outlined)
k
l
m
n
j Informal agreement (not signed, verbal, or otherwise non­comittal agreement)
k
l
m
n

j Other agreement (indicate the type of agreeemtn, and if it is considered formal or informal, or mixed)
k
l
m
n
j No formal or informal agreement (No MOU/ MAA established)
k
l
m
n

*19. Has a lead agency been identified to convene the coalition and asume significant

responsibility for ensuring the coalition is accomplishing its strategic goals?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

*20. Please name the lead agency

*21. Does your coalition receive funding from federal, state, or other sources?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

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Coalition Questionnaire

*22. What percentage of funding does the healthcare coaltion recieve from the following

sources? (Note all entries should total 100%)
Federal: ASPR/HPP
Federal: Centers for Disease Control & prevention (CDC)/ PHEP

Federal­Other: Federal Emergency Management Agency (FEMA), Centers for Medicare & Medicaid 
Services (CMS), Health Resource Services Administration (HRSA)
State Grants
Local Grants
Foundation Grants
Other Funding: Membership Dues, Private Sector Funding

*23. Does the coalition as a whole have a non­profit status?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

*24. Does a steering committee exist to oversee the overall coalition governance and

logistics?

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

*25. Does the coalition have the following? (Check all that apply)
c Defined and accepted roles and responsibilities
d
e
f
g
c Diverse and multidisciplinary membership
d
e
f
g
c Staffing support
d
e
f
g

c Established sub­committees
d
e
f
g

c Share risks across coaltion members (e.g., shared resources and feelings of reciprocity)
d
e
f
g
c Collaboration with other planning entities (i.e., MMRS, public safety, NGO, etc.)
d
e
f
g
c None of the above
d
e
f
g

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Coalition Questionnaire

*26. If subcommittees exist , what are the areas of interest captured by the

subcommittees? (Select One)
j EMS (Pre­hospital Care)
k
l
m
n

j Incident Command Structure (ICS) functions
k
l
m
n
j HPP capabilities
k
l
m
n

j Hazard vulnerability
k
l
m
n
j Credentialing
k
l
m
n

j Training and Exercises
k
l
m
n
j Funding
k
l
m
n

j Needs of At­Risk Individuals
k
l
m
n

j Other: Explain _____________________________________________
k
l
m
n
j No subcommittees established
k
l
m
n

*27. Is the coalition involved in the following medical surge activities? (Check all that

apply)

c Testing response systems considering several types of scenarios (e.g., Hazard Vulnerability)
d
e
f
g
c Addressing healthcare resource gaps (i.e., medical assets)
d
e
f
g
c Assisting healthcare organizations with surge capacity
d
e
f
g

c Managing and allocating scarce resources for response and recovery operations
d
e
f
g
c Developing mechanisms useful for patient tracking and redistribution
d
e
f
g
c Distributing emergency supplies and pharmaceutical caches
d
e
f
g
c Cross credentialing of healthcare or critical personnel
d
e
f
g
c None of these apply
d
e
f
g

Other (explain) 

*28. Active engagement within the coalition is evidenced by: (Check all that apply)
c Support of organizational members’ senior leadership (e.g. CEOs, COOs, Agency Directors)
d
e
f
g
c Active stakeholder involvement in all phases (planning, response, recovery)
d
e
f
g

c Regular scheduled meetings among members to address common challenges
d
e
f
g
c Consistent attendance among all members
d
e
f
g
c None of these apply
d
e
f
g

Page 9

Coalition Questionnaire

*29. Please indicate some primary preparedness and planning functions that the

coalition participates in on a routine basis. (Check all that apply)
j Natural and man­made disasters
k
l
m
n

j Public health and medical emergencies
k
l
m
n

j Terrorist threats or incidents involving chemical, biological, radiological, nuclear, or explosive (CBRNE) weapons
k
l
m
n
j Infectious disease outbreaks and pandemics
k
l
m
n

*30. Which of the following information sharing mechanisms are in place? (Check all that

apply)

c List of pre­identified points of contact (POCs) is internally and externally available
d
e
f
g
c Contact list (including POCs) is updated regularly (e.g., quarterly)
d
e
f
g

c Information sharing protocol that formalizes communication during activation
d
e
f
g

c Internal communication systems and protocols have been tested (e.g. real incidents, exercises)
d
e
f
g

c Communication systems and protocols have been tested between the coalition members and external organizations (e.g., real incidents, 
d
e
f
g
exercises) 

c Systems for communication with other coalitions (e.g. inter­coalition connectivity)
d
e
f
g

c Electronic data/information sharing systems (e.g., WebEOC, HAN, bed tracking, other, etc.)
d
e
f
g
c ESF­8 EOC activation is exercised at least 2 times/year, given there is no real incident
d
e
f
g
c Regional Fusion Center representation
d
e
f
g
c None of these apply
d
e
f
g

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Coalition Questionnaire

*31. If subcommittess exist, what are the areas of interest captured by the subcomittees?

(Select One)

j EMS (Pre­hospital Care)
k
l
m
n

j Incident Command Structure (ICS) functions
k
l
m
n
j HPP capabilities
k
l
m
n

j Hazard vulnerability
k
l
m
n
j Credentialing
k
l
m
n

j Training and Exercises
k
l
m
n
j Funding
k
l
m
n

j Needs of At­Risk Individuals
k
l
m
n

j No subcommittees established
k
l
m
n

Other (please specify) 

*32. Is the coalition involved in the following medical surge activities? (Check all that

apply)

c Testing response systems considering several types of scenarios (e.g., Hazard Vulnerability)Addressing healthcare resource gaps (i.e., 
d
e
f
g
medical assets) 

c Assisting healthcare organizations with surge capacity
d
e
f
g

c Managing and allocating scarce resources for response and recovery operations
d
e
f
g
c Developing mechanisms useful for patient tracking and redistribution
d
e
f
g
c Distributing emergency supplies and pharmaceutical caches
d
e
f
g
c Cross credentialing of healthcare or critical personnel
d
e
f
g
c None of these apply
d
e
f
g

Other (please specify) 

*33. Active engagement within the coalition is evidenced by: (Check all that apply)
c Support of organizational members’ senior leadership (e.g. CEOs, COOs, Agency Directors)
d
e
f
g
c Active stakeholder involvement in all phases (planning, response, recovery)
d
e
f
g

c Regular scheduled meetings among members to address common challenges
d
e
f
g
c Consistent attendance among all members
d
e
f
g
c None of these apply
d
e
f
g

Page 11

Coalition Questionnaire

*34. Please indicate some primary preparedness and planning functions that the coaltion

participates in on a routine basis. (Check all that apply)
c Natural and man­made disasters
d
e
f
g

c Public health and medical emergencies
d
e
f
g

c Terrorist threats or incidents involving chemical, biological, radiological, nuclear,
d
e
f
g
c or explosive (CBRNE) weapons
d
e
f
g

c Infectious disease outbreaks and pandemics
d
e
f
g

*35. Which of the following information sharing mechanisms are in place? (Check all that

apply)

c List of pre­identified points of contact (POCs) is internally and externally available
d
e
f
g
c Contact list (including POCs) is updated regularly (e.g., quarterly)
d
e
f
g

c Information sharing protocol that formalizes communication during activation
d
e
f
g

c Internal communication systems and protocols have been tested (e.g. real incidents, exercises)
d
e
f
g

c Communication systems and protocols have been tested between the coalition members and external organizations (e.g., real incidents, 
d
e
f
g
exercises) 

c Systems for communication with other coalitions (e.g. inter­coalition connectivity)
d
e
f
g

c Electronic data/information sharing systems (e.g., WebEOC, HAN, bed tracking, other, etc.)
d
e
f
g
c ESF­8 EOC activation is exercised at least 2 times/year, given there is no real incident
d
e
f
g
c Regional Fusion Center representation
d
e
f
g
c None of these apply
d
e
f
g

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Coalition Questionnaire

*36. Please indicate the type of information your coalition exchanges among your

members on a routine basis and during an event or exercises? (Check all that apply)
Routine

Event/Exercise

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Staffing Information

j
k
l
m
n

j
k
l
m
n

Electronic Medical Records 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Alternate Care Sites

j
k
l
m
n

j
k
l
m
n

Resources (e.g., Bed 

j
k
l
m
n

j
k
l
m
n

Generator Status

j
k
l
m
n

j
k
l
m
n

None of these apply

j
k
l
m
n

j
k
l
m
n

Clinical Information (e.g. 
Medical Procedures, Tests)
Epidemiology or 
Surveillance Data
Environmental Laboratory 
Reports

(e.g., Patient Transfer Use)
Evacuation Status (e.g., 
Patient tracking and 
redistribution information)

Surge/Availability)

Other (please specify) 

*37. Please select ways in which the coalition shares best practices, tools, and planning

processes. (Check all that apply)

c On­line planning website where members can post information (url:____________________)
d
e
f
g

c Single coalition­wide resource clearinghouse (e.g., resource document or online resource page)
d
e
f
g
c Regular meetings (i.e. , subcommittees meeting at least bimonthly)
d
e
f
g
c Quarterly newsletters/ bulletins
d
e
f
g
c Updated listservs
d
e
f
g
c Conferences
d
e
f
g

c Do not share best practices
d
e
f
g

Other (please specify) 

*38. Processes and protocols exist to utilize interoperable equipment?

j Yes
k
l
m
n
j No
k
l
m
n

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Coalition Questionnaire

*39. Interoperable equipment exists to effectively communicate during steady state or a

disaster among:
j Coalition members
k
l
m
n
j Other coalitions
k
l
m
n

j Both internal members and external groups
k
l
m
n
j Neither internal or external groups
k
l
m
n

*40. The coalition has developed a response plan that: (Check all that apply)
c Presents a clear description of roles and responsibilities (e.g., hospitals, EMS, and health departments)
d
e
f
g
c Provides a tested process map and/or decision tree for emergency and non­emergency scenarios
d
e
f
g
c Entails detailed protocols for joint purchasing
d
e
f
g

c Promotes joint hazard vulnerability assessment and planning
d
e
f
g

c Outlines the coalition’s coordination function for alternate care sites
d
e
f
g

c Assures checks and balances exist for appropriate oversight & distribution of power
d
e
f
g
c Establishes a system to convene needed personnel
d
e
f
g

c Incorporates a planned strategy for demobilization
d
e
f
g

c Facilitates decisions regarding the allocation of scarce resources
d
e
f
g

c None of these apply
d
e
f
g

*41. How would you rate the level of trust (i.e. reliability, having shared belief in mission,

and opportunity for frank discussions) among coalition members?
j A lot of trust
k
l
m
n

j Quite a bit of trust
k
l
m
n

j Moderate amount of trust
k
l
m
n
j A little trust
k
l
m
n

j No trust at all
k
l
m
n

*42. How many full scale exercises to test emergency response capabilities does your

coalition participate in annually (July 2011­ July 2012)?

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Coalition Questionnaire

*43. Has your coalition provided training and exercise activities in the following areas

between July 2011 and July 2012? (Check All that Apply)
Hazard Vulnerability 

Training

Exercise

Both

Neither

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Assessment (HVA) based
Immediate Response 
Capabilities (e.g. Medical 
Surge)
Joint plans that includes 
objectives
Schedule for joint activities 
published
Emergency Medical Care 
and Operations
Evaluation tools developed 
to assess exercises
Lessons learned (LL) 
captured in a Corrective 
Action Plan
Corrective Action Plan 
(CAP) is developed
Evaluation of LLs 
Implementation from prior 
CAPs
Other (please specify) 

Page 15

Coalition Questionnaire

*44. Please rate your perception of the coalition's level of progress within the past 5

years in the following areas:

No Progress

Slight Progress

Moderate Progress

A Lot of Progress

Great Progress

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Coordination of Efforts

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Readiness Planning

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Fatality Management

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Education & Training (e.g., 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Short­Term Recovery

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Leveraging Resources

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Allocation of Scarce 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Sustainability

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Involvement of Community 

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

j
k
l
m
n

Integrated Communication 
\Info Sharing

drills & exercises)
Medical 
Evacuation/Shelter­in­
Place

Resources
Critical Infrastructure 
Protection
Volunteerism (e.g., Emer. 
System for Advance 
Registration of Volunteer 
Health Professionals
Addressing the Needs of At­
Risk Populations
Integration of Behavioral 
Health

Members and Orgs

*45. Does the coalition assist in meeting routine, non­disaster preparedness challenges?

(Select One)

j Yes
k
l
m
n
j No
k
l
m
n

j Unsure
k
l
m
n

Page 16

Coalition Questionnaire

*46. Please provide a brief example(s) of how the coalition has routinely met challenges.
5

6  

*47. Please describe the barriers in the coalition meeting the routine challenges.
5

6  

*48. How would you rate the level of engagement and/or education offered by the

coalition to community members and organizations who are not part of the coalition (e.g.
use of the public engagement tool on crisis standards of care)? (Select One)
j A lot of community engagement
k
l
m
n

j Quite a bit of community engagement
k
l
m
n
j Moderate community engagement
k
l
m
n
j A little community engagement
k
l
m
n
j No community engagement
k
l
m
n

*49. Briefly describe three overarching accomplishments of the coalition? (Limit to 100

characters)
1
2
3

Page 17

Coalition Questionnaire

*50. Please complete this sentence, “The coalitions’ sustainability efforts

include…” (Check all that apply)

c Addressing complex issues in healthcare preparedness, response, and recovery
d
e
f
g
c Communicating achievements to internal and external stakeholders
d
e
f
g

c Confirming a commitment to a relevant, agreed upon long term vision
d
e
f
g

c Representing ongoing working relationships with pertinent institutions and individuals
d
e
f
g
c Incorporating direct community input
d
e
f
g

c Ensuring internal systems foster participation
d
e
f
g
c Promoting a shared financial commitment
d
e
f
g
c Securing diverse funding mechanisms
d
e
f
g

c Providing a unique service (e.g., allocation of scarce resources, coordination, etc.)
d
e
f
g
c Maintaining coalition services and participation despite diminishing grant funds
d
e
f
g
c None of these apply
d
e
f
g

Page 18