Exercise Findings Form

Form Approved

OMB No. 0920-0879

Exp. Date 02/18/2018

INSTRUCTIONS (Appendix D)

Exercise Findings Form is a voluntary assessment that gathers the top strengths and areas needing improvement from each state following the exercise. It is to be completed by the exercise planners / facilitators within each state. Please complete the form electronically and submit via email to [email protected] by 9/15/2016. This collected data will be shared in aggregate in a summary report that the CDC will draft and share with participating states during the HHS Region VI VTTX Follow-up Meeting on Sept 29, 2016. It is estimated that completion of this assessment will take no longer than 120 minutes.

EXERCISE FINDINGS FORM (Appendix A)

Strengths

1. I observed the following strengths during this exercise (please select the corresponding capability and applicable element related to the strength):

Strengths	Core Capability	Element
[list observed strength]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise
[list observed strength]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise
[list observed strength]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise

Areas for Improvement

2. I observed the following areas for improvement during this exercise (please select the corresponding capability and applicable element related to the area for improvement):

Areas for Improvement	Core Capability	Element
[list area for improvement]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise
[list area for improvement]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise
[list area for improvement]	[list core capability for this exercise]	Planning
		Organization
		Equipment
		Training
		Exercise

CDC estimates the average public reporting burden for this collection of information as 2 hours per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1050).