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pdfForm Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Fellowship Management System (FMS)
FMS Host Site Module
2020
Privacy Act and Public Burden Information
Privacy Act Information
The Privacy Act applies to this information collection. Information collected will be kept private as noted in the System of Records Notice is 09-20-0112,
Fellowship Program and Guest Researcher Records.
Public Burden Information
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Public reporting burden of this collection of information is an estimated average of 66 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data 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
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0765).
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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table of Contents
Table of Contents ........................................................................................................................................................................................................... 2
1.
Introduction ........................................................................................................................................................................................................... 5
1.1
2.
Document Structure....................................................................................................................................................................................... 6
Sign-In & Sign-Up Pages ......................................................................................................................................................................................... 7
2.1
Sign-In Page .................................................................................................................................................................................................... 7
2.2
Sign-Up Page (For New Users) ....................................................................................................................................................................... 9
3.
eFMS System Help Desk Ticket ............................................................................................................................................................................ 10
4.
Application Welcome Page .................................................................................................................................................................................. 12
5.
Applicant Profile................................................................................................................................................................................................... 13
6.
5.1
Create a Profile to Get Started..................................................................................................................................................................... 13
5.2
Primary Application Contact ........................................................................................................................................................................ 14
5.3
Public Health Agency Details ....................................................................................................................................................................... 15
Position Assignment Details................................................................................................................................................................................. 19
6.1
Get Started ................................................................................................................................................................................................... 19
6.2
Position Assignment Details......................................................................................................................................................................... 20
6.3
Position Assignment Environment ............................................................................................................................................................... 22
6.4
Travel Opportunities .................................................................................................................................................................................... 25
6.5
Position Assignment Location ...................................................................................................................................................................... 27
6.6
Consultants & Officer/Fellow Details ........................................................................................................................................................... 29
6.7
EIS ................................................................................................................................................................................................................. 30
6.7.1
Proposed Projects ................................................................................................................................................................................ 30
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Attachment 5 – FMS Host Site Module
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OMB No. 0920-0765
Exp. Date 03/31/2023
6.7.2 Other Position Assignment Details ............................................................................................................................................................. 32
6.8
LLS ................................................................................................................................................................................................................ 35
6.8.1
6.9
EEP................................................................................................................................................................................................................ 36
6.9.1
6.10
7.
Position Assignment Details ................................................................................................................................................................. 43
PE ................................................................................................................................................................................................................. 44
6.13.1
6.14
Long-Term Trainee Support & Projects ............................................................................................................................................... 41
PHIFP ............................................................................................................................................................................................................ 43
6.12.1
6.13
Host Site Information ........................................................................................................................................................................... 39
PMR/F .......................................................................................................................................................................................................... 41
6.11.1
6.12
Position Assignment Details ................................................................................................................................................................. 36
FLIGHT .......................................................................................................................................................................................................... 39
6.10.1
6.11
Position Assignment Details ................................................................................................................................................................. 35
Position Assignment Details ................................................................................................................................................................. 44
PHAP............................................................................................................................................................................................................. 45
6.14.1
Position Assignment Description ......................................................................................................................................................... 45
6.14.2
Subject Area Proposed Assignment ..................................................................................................................................................... 47
6.14.3
Assignment Requests ........................................................................................................................................................................... 49
6.14.4
Other Public Health Agency Details ..................................................................................................................................................... 50
6.14.5
Letter of Support .................................................................................................................................................................................. 51
6.14.6
Population Information........................................................................................................................................................................ 52
6.14.7
Orientation ........................................................................................................................................................................................... 55
Supervisors ........................................................................................................................................................................................................... 56
7.1
Adding New Supervisors .............................................................................................................................................................................. 56
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Attachment 5 – FMS Host Site Module
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OMB No. 0920-0765
Exp. Date 03/31/2023
7.2
Supervisor Information ................................................................................................................................................................................ 58
7.3
Supervisor Experience.................................................................................................................................................................................. 60
7.4
Mentoring Experience.................................................................................................................................................................................. 65
8.
Activities/Projects ................................................................................................................................................................................................ 67
8.1
Activity/Project Details ................................................................................................................................................................................ 67
8.2
Activity/Project Location.............................................................................................................................................................................. 70
8.3
Activity & Deliverable Details....................................................................................................................................................................... 71
8.4
Competencies .............................................................................................................................................................................................. 72
9.
8.4.1
PHIFP .................................................................................................................................................................................................... 72
8.4.2
PHAP..................................................................................................................................................................................................... 74
Training & Languages ........................................................................................................................................................................................... 79
9.1
10.
10.1
11.
11.1
12.
PHAP............................................................................................................................................................................................................. 79
Student Rotation Preferences.......................................................................................................................................................................... 81
EEP................................................................................................................................................................................................................ 81
Match ............................................................................................................................................................................................................... 83
Match or Prematch Rank/Rating Form ........................................................................................................................................................ 83
Appendix .......................................................................................................................................................................................................... 84
I. Field Value Tables ................................................................................................................................................................................................. 85
II. Lookup Tables ...................................................................................................................................................................................................... 87
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Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
1. Introduction
The purpose of this document is to list all the data elements of the host site application collected online through the Fellowship
Management System (FMS). The FMS online host site assignment module is a streamlined mechanism for agencies, who are interested in
hosting fellows of the Centers for Disease Control and Prevention (CDC) fellowships to submit their assignment proposals online and track
statuses of the application processes. The FMS is a robust flexible framework and is successfully tailored for various CDC fellowships. The
following fellowships use the FMS Host Site Application module to collect applications from federal and non-federal public health agencies
and organizations:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Epidemic Intelligence Service (EIS)
CDC E-learning Institute (ELI)
Epidemiology Elective Program (EEP)
Future Leaders in Infections and Global Health Threats (FLIGHT)
Laboratory Leadership Service (LLS)
CDC Steven M. Teutsch Prevention Effectiveness (PE) Fellowship
Public Health Associate Program (PHAP)
Public Health Informatics Fellowship Program (PHIFP)
Science Ambassador Fellowship (SAF)
Preventive Medicine Residency and Fellowship (PMR/F)
Population Health Training in Place Program (PH-TIPP)
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Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
1.1 Document Structure
This document is broken down by the major pages of the FMS Host Site Application. In this document, each page of the FMS Host Site
Application has sections and some sub-sections. In addition, application instructions, login, and registration pages are included.
Following the screenshots in each section is a table that shows the status of the collection of data elements by each CDC fellowships. The
following labels indicate the status of the collection:
•
“Yes” indicates that the fellowship collects the information and that alumni are required to submit this information.
•
“No” indicates that the fellowship does not collect this information.
•
“-“ indicates open text field
In addition, the table shows the data values of each data element, and for ones that have a list of dropdown values, the data value category
is hyperlinked to its list located in the Appendix.
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OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
2. Sign-In & Sign-Up Pages
2.1 Sign-In Page
Figure 2.1-a. Sign-In Page
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Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Figure 2.1-b. Privacy Act and Public Burden Information
Table 2.1-a. Sign-In Fields
Field
Email
Values
-
EIS
Yes
LLS
Yes
FLIGHT
Yes
EEP
Yes
SAF
Yes
PMR/F
Yes
PH-TIPP
Yes
PHIFP
Yes
PE
Yes
ELI
Yes
PHAP
Yes
Password
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
2.2 Sign-Up Page (For New Users)
Figure 2.2-a. Sign-Up Fields
Table 2.2-a. Sign-Up Fields
Field
Values
-
EIS
Yes
LLS
Yes
FLIGHT
Yes
EEP
Yes
SAF
Yes
PMR/F
Yes
PH-TIPP
Yes
PHIFP
Yes
PE
Yes
ELI
Yes
PHAP
Yes
Password
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Confirm Password
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Email
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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
3. eFMS System Help Desk Ticket
Figure 3-a. eFMS System Help Desk Ticket Fields
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OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 3-a. eFMS System Help Desk Ticket Fields
Field
Values
-
EIS
Yes
LLS
Yes
FLIGHT
Yes
EEP
Yes
SAF
Yes
PMR/F
Yes
PH-TIPP
Yes
PHIFP
Yes
PE
Yes
ELI
Yes
PHAP
Yes
Sign-In Email:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Contact Phone Number:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Your Name:
Fellowship:
Fellowship Lookup Table
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
What type of issue or need do you have?
1. System Error Message
2. Sign-In or Password
3. Smart Card Sign-In
4. Data Not Saving
5. Unable to Submit
6. Reset application back to "Draft"
7. Withdraw Fellowship Application
8. Other
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
URL where the issue is occurring:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Error code message:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Please describe your issue or need:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Screenshot of error or issue (optional):
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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Attachment 5 – FMS Host Site Module
4. Application Welcome Page
Figure 4-a. Application Welcome Page
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Attachment 5 – FMS Host Site Module
5. Applicant Profile
5.1 Create a Profile to Get Started
Figure 5.1-a. Create a Profile to Get Started
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Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
5.2 Primary Application Contact
Figure 5.2-a. Primary Application Contact Fields
Table 5.2-a. Primary Application Contact Fields
Field Name
Primary Contact Name:
Primary Contact Email:
Primary Contact Role/Position:
Office Phone Number:
Alternate Email:
Mobile Number:
Values
-
EIS
Yes
Yes
Yes
Yes
Yes
Yes
LLS
Yes
Yes
Yes
Yes
Yes
Yes
EEP
Yes
Yes
Yes
Yes
Yes
Yes
FLIGHT
Yes
Yes
Yes
Yes
Yes
Yes
PMR/F
Yes
Yes
Yes
Yes
Yes
Yes
PHIFP
Yes
Yes
Yes
Yes
Yes
Yes
PE
Yes
Yes
Yes
Yes
Yes
Yes
PHAP
Yes
Yes
Yes
Yes
Yes
Yes
14
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
5.3 Public Health Agency Details
Figure 5.3-a. Public Health Agency Details Fields
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Attachment 5 – FMS Host Site Module
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OMB No. 0920-0765
Exp. Date 03/31/2023
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OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Figure 5.3-a. Public Health Agency Details Fields
Field Name
Public Health Agency
Type:
Center/Division/Branch:
Public Health Agency:
Agency Name:
Agency Center:
Agency Division:
Agency Branch:
Organization Name:
CDC Campus:
Building:
Street Address:
Street Address Line 2:
Street Address Line 3:
Suite, Room:
Country:
State/Territory:
State/Province:
City:
Zip Code:
COVID-19 Operations: Is
your organization’s
physical office open,
closed (100% telework),
hybrid model of the two,
Values
1. CDC
2. Federal Government (Other)
3. State
4. Local
5. Territorial
6. Tribal
7. Community-based Organization
8. Indian Health Service area offices
9. University or other academia
10. Private public health organization
11. Non-profit organization
12. Other
Public Health Agency Lookup
CDC Campus Lookup
State/Territory Lookup
1. Open (No telework)
2. Closed (100% telework)
3. Hybrid (Alternating open & telework)
4. Other
EIS
Yes
LLS
Yes
EEP
Yes
FLIGHT
Yes
PMR/F
Yes
PHIFP
Yes
PE
Yes
PHAP
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
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Attachment 5 – FMS Host Site Module
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OMB No. 0920-0765
Exp. Date 03/31/2023
or other arrangements
due to COVID-19 public
health measures?
18
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
6. Position Assignment Details
6.1 Get Started
Figure 6.1-a. Get Started
Figure 6.1-b. Get Started
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Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.2 Position Assignment Details
Figure 6.2-a. Position Assignment Detail Fields
Figure 6.2-b. Position Assignment Detail Fields
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OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.2-a. Position Assignment Detail Fields
Field Name
Values
-
EIS
Yes
Yes
Yes
LLS
Yes
Yes
No
EEP
Yes
No
No
FLIGHT
Yes
Yes
No
PMR/F
Yes
No
No
PHIFP
No
No
No
PE
No
No
No
PHAP
No
No
No
-
No
Yes
No
Yes
No
No
Yes
No
Yes
No
No
No
No
No
No
No
Position Assignment Strengths:
Describe the data that the position
owns and has readily available for the
candidate:
Special skills useful for this position:
Selected Recent Host Site Publications:
-
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
-
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
Yes
No
Yes
No
No
No
Fellow/Officer/Student Publications:
-
Yes
Yes
No
Yes
No
No
No
No
Background:
Proposed Initial Project(s):
Short title for the position:
Help Text: Field positions, please input
the short title provided to you by EWB
Leadership opportunities:
Describe the breadth of work that the
candidate will experience:
21
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
6.3 Position Assignment Environment
Figure 6.3-a. Position Assignment Environment Fields
22
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.3-a. Position Assignment Environment Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Describe the program area, department, or organizational unit within the public health
agency where the position assignment will be based. Include information on the
number of employees/departments/divisions/branches/teams:
-
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Describe the staff and other resources available:
Describe in detail the workplace support that will be provided (e.g., office setting,
computer equipment, clerical and administrative support, peer support, dedicated
resources):
-
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
What recent changes or upcoming reorganizations may impact the assignment(s) or
supervisor assigned to the candidate?
-
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Please attach a PDF of the current organizational chart for the public health agency:
-
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Please describe the size of the community, university affiliations, living environment,
cultural and recreational assets, and opportunities for the candidate's partner's
employment:
-
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Please describe the availability of safe and affordable housing in a commutable
distance (including any special arrangements provided for other staff or previous
associates).
-
No
No
No
No
No
No
No
Yes
Please describe any additional administrative requirements (i.e. type) for accepting a
federal assignee.
-
No
No
No
No
No
No
No
Yes
1.Scheduled
Meeting
with LLS
Program
2.PD
Approved by
CIO
Authority
No
Yes
No
No
No
No
No
No
Select the following to confirm that you have: (required)
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Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.4 Travel Opportunities
Figure 6.4-a. Travel Opportunities Fields
Table 6.4-a. Travel Opportunities Fields
Field Name
Domestic Travel:
International Travel:
Values
0% - 100% in increments of 10
0% - 100% in increments of 10
EIS
Yes
Yes
LLS
Yes
Yes
EEP
No
No
FLIGHT
Yes
Yes
PMR/F
No
No
PHIFP
No
No
PE
No
No
PHAP
No
No
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Attachment 5 – FMS Host Site Module
Local Travel (outside of 100 miles from
host site assignment location):
0% - 100% in increments of 10
No
No
No
No
No
No
No
Yes
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Attachment 5 – FMS Host Site Module
6.5 Position Assignment Location
Figure 6.5-a. Position Assignment Location Fields
Figure 6.5-b. Position Assignment Location Fields
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OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.5-a. Position Assignment Location Fields
Field Name
Is the Position Assignment Location the same as
the Public Health Agency Location?
Physical Address:
Address Line 2:
Address Line 3:
Suite, Room:
Country:
State/Territory:
State/Province:
City:
Zip Code:
Is mailing address different?
Mailing Address:
Mailing Address Line 2:
Mailing Address Line 3:
Suite, Room:
Country:
State/Territory:
State/Province:
City:
Zip Code:
Values
EIS
Yes
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
1. Yes
2. No
Country List
State/Territory List
1. Yes
Country List
State/Territory List
-
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Attachment 5 – FMS Host Site Module
6.6 Consultants & Officer/Fellow Details
Figure 6.6-a. Consultants & Officer/Fellow Details Fields
Table 6.6-a. Consultants & Officer/Fellow Details Fields
Field Name
Please include the following information for consultants and
officers/fellows in the text boxes below:
- Full Name
- Emails
- Current Titles
- Degrees
- Fellowship Year
- Alumni Status
Consultants:
Officers/Fellows:
Values
-
EIS
Yes
LLS
Yes
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
No
-
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
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Attachment 5 – FMS Host Site Module
6.7 EIS
6.7.1 Proposed Projects
Figure 6.7.1-a. Proposed Projects Fields
Figure 6.7.1-b. Proposed Projects Fields
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Attachment 5 – FMS Host Site Module
Figure 6.7.1-a. Proposed Projects Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Briefly describe the host site proposed
projects:
-
Yes
No
No
No
No
No
No
No
Proposed Analytic Project(s):
-
Yes
No
No
No
No
No
No
No
Opportunities for primary data collection
to fulfill the Field Investigation CAL:
-
Yes
No
No
No
No
No
No
No
Opportunities to collaborate with public
health partners:
-
Yes
No
No
No
No
No
No
No
Proposed Surveillance Project:
-
Yes
No
No
No
No
No
No
No
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Exp. Date 03/31/2023
6.7.2 Other Position Assignment Details
Figure 6.7.2-a. Other Position Assignment Details Fields
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Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.7.2-a. Other Position Assignment Details Fields
Field Name
Is this a pre-match position?
Values
1. Yes
2. No
Describe why this position should be
considered for a pre-match:
Will this position be funded by the host
site or the EIS/LLS program?
-
1. Host Site
2. EIS/LLS Program
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
33
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
If the position is not selected to be
1. Yes
funded by the EIS/LLS program will the 2. No
host site be willing to fund the position?
Yes
Yes
No
No
No
No
No
No
Is this a pre-match [OR OTHER CDC
PRIORITY PROCESS] position?
No
Yes
No
No
No
No
No
No
1. Yes
2. No
Describe why this position should be
considered for a pre-match/[OR OTHER
CDC PRIORITY PROCESS].
34
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.8 LLS
6.8.1 Position Assignment Details
Figure 6.8.1-a. Position Assignment Details Fields
Table 6.8.1-a. Position Assignment Details Fields
Field Name
Routine Lab Work:
Values
-
EIS
No
LLS
Yes
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
No
35
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
6.9 EEP
6.9.1 Position Assignment Details
Figure 6.9.1-a. Position Assignment Details Fields
36
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.9.1-a. Position Assignment Details Fields
Field Name
Rotation Title:
How would you best describe the subject area covered
in this position?
Specify:
Values
1. Obesity, nutrition, and physical activity
2. Cancer prevention and control
3. Diabetes
4. Heart disease and stroke prevention
5. Tobacco prevention and cessation
6. Other chronic disease
7. Emergency preparedness and response
8. Asthma and air pollution
9. Environmental health
10. Immunizations/vaccine preventable disease
11. Influenza
12. HIV/AIDS or Tuberculosis
13. Viral hepatitis
14. Foodborne Disease
15. Waterborne diseases
16. Vectorborne disease
17. One Health and zoonotic disease
18. Arctic Investigations (Alaska)
19. Healthcare-associated infections
20. Quarantine and border health services
21. Unintentional injury
22. Opioid/prescription drug overdose prevention
23. Occupational health and safety
24. Violence Prevention
25. Maternal and infant health
26. Health statistics
27. State, local, and territorial health
28. Global health
29. Other (specify)
-
EIS
No
No
LLS
No
No
EEP
Yes
Yes
FLIGHT
No
No
PMR/F
No
No
PHIFP
No
No
PE
No
No
PHAP
No
No
37
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.9.1-b. Position Assignment Details Fields
Field Name
What type of project(s) will the
student(s) likely be assisting with?
(Select all that may apply)
Values
1. Data collection
2. Data entry
3. Data analysis
4. Intervention/program planning
5. Intervention/program
implementation
6. Intervention/program evaluation
7. Literature review
8. Scientific writing (e.g., drafting a
section of a report)
9. Communications/design (e.g.,
developing flyers, website content)
10. Field investigation
11. Other:
EIS
No
LLS
No
EEP
Yes
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
No
Specify:
-
No
No
Yes
No
No
No
No
No
Additional Details:
-
No
No
Yes
No
No
No
No
No
38
Attachment 5 – FMS Host Site Module
6.10
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
FLIGHT
6.10.1 Host Site Information
Figure 6.10.1-a. Host Site Information Fields
39
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.10.1-a. Host Site Information Fields
Field Name
Public health science or research
projects:
Opportunities to collaborate with
public health partners:
Host site strengths:
Describe other staff and resources
available at the host site:
Special skills in a candidate that are
useful for this host site:
Values
-
EIS
No
LLS
No
EEP
No
FLIGHT
Yes
PMR/F
No
PHIFP
No
PE
No
PHAP
No
-
No
No
No
Yes
No
No
No
No
-
No
No
No
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
-
No
No
No
Yes
No
No
No
No
40
Attachment 5 – FMS Host Site Module
6.11
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
PMR/F
6.11.1 Long-Term Trainee Support & Projects
Figure 6.11.1-a. Long-Term Trainee Support & Projects
41
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.11.1-a. Long-Term Trainee Support & Projects
Field Name
Describe the program's experience
with supporting long-term trainees:
Program Evaluation:
Policy Analysis or Development:
Population Health Improvement:
Project Management:
Grant Proposal Evaluation and
Development:
Values
-
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
Yes
PHIFP
No
PE
No
PHAP
No
-
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
42
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.12
PHIFP
6.12.1 Position Assignment Details
Figure 6.12.1-a. Position Assignment Details
Table 6.12.1-a. Position Assignment Details
Field Name
How many fellows will be requested
for this assignment?
Will any of these positions be
prematched?
Values
1. Yes
2. No
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
Yes
PE
No
PHAP
No
No
No
No
No
No
Yes
No
No
Name(s) of applicant(s) considered for
prematch:
-
No
No
No
No
No
Yes
No
No
Describe training opportunities for the
fellow:
-
No
No
No
No
No
Yes
No
No
43
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.13
PE
6.13.1 Position Assignment Details
Figure 6.13.1-a. Position Assignment Details
Table 6.13.1-a. Position Assignment Details
Field Name
Describe the assignment setting:
Values
-
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
Yes
PHAP
No
44
Attachment 5 – FMS Host Site Module
6.14
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
PHAP
6.14.1 Position Assignment Description
Figure 6.14.1-a. Position Assignment Description Fields
45
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.14.1-a. Position Assignment Description Fields
Field Name
Please describe in detail your need for a Public Health Associate:
Position Description: Please briefly describe the proposed assignment for the
associate (this will be shared with the associate after selection).
How will this address the need identified in the previous question?
Describe how the associate will primarily work with others as part of a team,
independently, coordinating or leading activities, or with external stakeholders.
Values
-
EIS
No
No
LLS
No
No
EEP
No
No
FLIGHT
No
No
PMR/F
No
No
PHIFP
No
No
PE
No
No
PHAP
Yes
Yes
-
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
What will your host site offer candidates that similar host sites may not?
-
No
No
No
No
No
No
No
Yes
If the associate was not a CDC employee, but was an employee of your
organization, their position title would be:
-
No
No
No
No
No
No
No
Yes
46
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
6.14.2 Subject Area Proposed Assignment
Figure 6.14.2-a. Subject Area Proposed Assignment Fields
47
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.14.2-a. Subject Area Proposed Assignment Fields
Field Name
Select the subject area the associate will be
working in for the majority of their assignment:
Values
Adolescent & School Health (non-STI)
Community Health Improvement Planning
(CHIP)/Community Health Assessments (CHA)
Chronic Disease: Population Health
Emergency/Disaster Preparedness and
Response
Environmental Health (General)
Health Equity/Access to Care (General)
Health Department Improvement/Accreditation
Immunizations/Vaccine Preventable Disease
Investigation
Sexually Transmitted Disease Prevention
HIV/AIDS Prevention
Tuberculosis Prevention
Viral Hepatitis Prevention
Adolescent & School Health (non-STI):
Adolescent/school-based Sexually Transmitted
Disease Prevention Disease Prevention
Other Infectious Disease
Injury Prevention: Violence (Interpersonal)
Maternal & Child Health
Public Health Policy & Law
Public Health Surveillance (General)
Oral Health
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
48
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.14.3 Assignment Requests
Figure 6.14.3-a. Assignment Request Fields
Table 6.14.3-a. Assignment Request Fields
Field Name
Driver’s License required:
Personal vehicle required:
Values
1. Yes
2. No
1. Yes
2. No
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
No
No
No
No
No
No
No
Yes
49
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.14.4 Other Public Health Agency Details
Figure 6.14.4-a. Other Public Health Agency Detail Fields
Table 6.14.4-a. Other Public Health Agency Detail Fields
Field Name
Does the building in which the
associate will be working meet the
requirements under the Americans
with Disabilities Act (ADA)?
Is the location of the public health
agency considered rural?
Is the location of the public health
agency on an Indian Reservation?
Values
1. Yes
2. No
1. Yes
2. No
1. Yes
2. No
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
50
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.14.5 Letter of Support
Figure 6.14.5-a. Letter of Support Fields
Table 6.14.5-a. Letter of Support Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Please attach a pdf of a letter of support on your agency’s letterhead.
The letter must be written and signed by the agency Director or a
senior leader.
-
No
No
No
No
No
No
No
Yes
Director or Leader Name:
-
No
No
No
No
No
No
No
Yes
Director or Leader Email:
-
No
No
No
No
No
No
No
Yes
Director or Leader Phone:
-
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
Director or Leader Phone Ext:
51
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
6.14.6 Population Information
Figure 6.14.6-a. Population Information Fields
52
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 6.14.6-a. Population Information Fields
Field Name
Level of Population Served:
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
-
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
-
No
No
No
No
No
No
No
Yes
1. American Indian or Alaska
2. Asian
3. Black or African American
4. Native Hawaiian or Pacific Islander
5. White
No
No
No
No
No
No
No
Yes
Ethnicity:
Age:
1. Hispanic or Latino
1. Under 5 years
2. 5 - 17 years
3. 18 - 24 years
4. 25 - 44 years
5. 45 - 64 years
6. 65 years and over
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Sex:
1. Male
2. Female
3. Other
No
No
No
No
No
No
No
Yes
Using the radio button options below, please
select from one of the following mutuallyexclusive criteria to classify this assignment as a
tribal or tribally-focused assignment. An
assignment would be considered “tribal” or
“tribally focused PHAP assignment” if any one (1)
of the following criteria are met:
1. Tribe: An Indian or Alaska Native tribe, band,
pueblo, village, or community that the Secretary
of the Interior acknowledges to exist as an
Indian tribe pursuant to the Federally
Recognized Indian Tribe List Act of 1994, 25 USC
5130 reclassified.
2. Tribal organizations include the following:
a. Regional Intertribal Organizations
such as All Indian Pueblo Council,
No
No
No
No
No
No
No
Yes
Specify:
Is this a tribal-focused assignment or does is
serve a predominately tribal population?
Estimated population impacted by the Public
Health Associate’s work:
Racial Category:
Values
1. State
2. County/Parish/Borough
3. Local
4. Other
1. Yes
2. No
53
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Great Lakes Intertribal Council, and
United South and Eastern Tribes
b. National Indian Organizations such
as National Indian Health Board,
National Native American AIDS
Prevention Center, etc.
c. Tribal Epidemiology Centers (TECs)
1.Federal agency with a tribal focus: Any agency
within the federal government that is
responsible for providing services to American
Indians and Alaska Natives including but not
limited to the following:
a.Indian Health Service (IHS)
b.Environmental Protection Agency
(EPA)
c.Bureau of Indian Affairs (BIA)
2.Assignment working with elected American
Indian/Alaska Native (AI/AN) tribal leaders: This
includes any PHAP assignment in a state health
department, local health department,
nongovernmental organization (NGO),
university, or non-federally recognized state
tribal organization with associate work activities
actively engaged with elected American
Indian/Alaska Native (AI/AN) tribal leaders.
Select the best option to classify this assignment
using the above criteria as tribal or triballyfocused serving a predominately tribal
population:
1. Tribe
2. Tribal Organization
3. Federal agency with a tribal focus
4. Assignment working with AI/AN tribal leaders
No
No
No
No
No
No
No
Yes
54
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
6.14.7 Orientation
Table 6.14.7-a. Orientation Fields
Table 6.14.7-a. Orientation Fields
Field Name
Is there a standard process at your agency to
orient new employees?
Values
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
Describe the associate’s orientation to the host
site and assignment (250 word limit).
-
No
No
No
No
No
No
No
Yes
Signed Agreement to Participate Upload:
-
No
No
No
No
No
No
No
Yes
1. Yes
2. No
55
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
7. Supervisors
7.1 Adding New Supervisors
Figure 7.1-a. Adding New Supervisors Fields
Figure 7.1-b. Adding New Supervisors Fields
Figure 7.1-c. Adding New Supervisors Fields
56
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.1-a. Adding New Supervisors Fields
FLIGHT
PMR/F
PHIFP
Do you want to proceed?
Field Name
1. Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Search and Select Individual: (By Name or Email)
Supervisor Lookup Table
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Role:
1. Primary Supervisor
2. Secondary Supervisor
3. Reviewer/Interviewer/Administrator
4. Mentor
1. Team Lead
2. Branch Chief
3. Division Director
4. CIO Director
5. Epidemiologist
6. Medical Epidemiologist
7. Medical Officer
8. Health Scientist
9. Public Health Advisor
10. Public Health Associate
11. Other
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Full Name:
CDC Employee?:
Job Title:
Specify Job Title:
Physical Address:
Unit:
Degrees:
Primary Email (CDC Staff Must Use CDC Email):
Primary Phone Number:
Alternate Phone Number:
Mobile/Cell Phone Number:
Ext:
Values
EIS
LLS
EEP
PE
PHAP
57
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
7.2 Supervisor Information
Figure 7.2-a. Supervisor Information Fields
58
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.2-a. Supervisor Information Fields
Field Name
Is the supervisor a full-time employee at the organization where
the fellow/associate will spend most of their time?
Values
EIS
Yes
LLS
Yes
EEP
No
FLIGHT
Yes
PMR/F
Yes
PHIFP
Yes
PE
No
PHAP
Yes
Supervisor Employed By:
How much time per week (hours) can the supervisor devote to
supervise?
-
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
If the Primary Supervisor is unable to continue supervision, can the
Secondary Supervisor step in?
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Supervisor list of 3 most relevant authored publications:
In what year did the supervisor start the fellowship program(s):
Is the supervisor an alumnus of any CDC fellowship or training
program?
-
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
Yes
Yes
CDC Fellowship List
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Specify:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
List the class year for each alumnus fellowship/program:
-
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
Which of the following CDC fellowship(s)/program(s) is the
Supervisor an alumnus of:
Select the following to confirm that you have: (required)
1. Yes
2. No
1. Yes
2. No
1. Scheduled
Meeting with LLS
Program
2. PD Approved by
CIO Authority
59
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
7.3 Supervisor Experience
Figure 7.3-a. Supervisor Experience Fields
Figure 7.3-b. Supervisor Experience Fields
60
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Figure 7.3-c. Supervisor Experience Fields
61
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.3-a. Supervisor Experience Fields
Field Name
Values
EIS
LLS
EEP FLIGHT
PMR/F
PHIFP
PE
PHAP
Years of public health experience:
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Describe the public health experience
of the supervisor (or additional staff)
relevant to the associate’s assignment:
-
No
No
No
No
No
No
No
Yes
Does the Supervisor have supervisory 1. Yes
experience?
2. No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Supervisory Experience (Select all that 1. I have supervised staff within my organization.
2. I have supervised fellows/associates in this
apply):
fellowship/program.
3. I have supervised fellows/associates in other
fellowships/programs.
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
How many years as a Primary
Supervisor for this
fellowship/program?
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
How many years as a Secondary
Supervisor for this
fellowship/program?
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
How many years as a Supervisor
overall?
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
62
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.3-b. Supervisor Experience Fields
Field Name
Has the Supervisor had formal supervisor training?
Values
1. Yes
2. No
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Yes
Yes
No
Yes
No
Yes
No
Yes
Current number of total staff supervised:
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Please provide the full name, class year, and email address of fellows/associates
from this fellowship/program supervised over the past 5 years:
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Please provide the fellowship, fellow name, class year, and email address of
fellows supervised from other fellowships.
-
Yes
Yes
No
Yes
Yes
Yes
No
No
Last year supervised a fellow/associate from this fellowship/program?
-
Yes
Yes
No
Yes
Yes
Yes
No
Yes
63
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.3-c. Supervisor Experience Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Describe the Supervisor's supervisory experience and style:
-
Yes
Yes
No
Yes
No
Yes
No
Yes
Please outline a brief supervision plan that will ensure appropriate on-the-job
training, management of the officer’s workload and performance, and support
for the officer’s professional and personal growth. This plan should include 1)
each supervisor’s role on the team; 2) communication methods and meeting
frequency with the officer, and 3) how the team will facilitate engagement of
the officer with others in the host site.
-
Yes
No
No
Yes
No
Yes
No
Yes
Please outline a brief supervision plan that will ensure appropriate on-the-job
training, management of the fellow’s workload and performance, and support
for the officer’s professional and personal growth. This plan should include 1)
each supervisor’s role on the team; 2) communication methods and meeting
frequency with the fellow, and 3) how the team will facilitate engagement of
the officer with others, including senior leadership, in the host site.
-
No
Yes
No
No
No
No
No
No
Describe a situation in which you had to juggle several challenging projects at
the same time. Please describe your approach as a supervisor to managing
priorities, delegating tasks, communicating expectations, and addressing any
changes in directives.
-
No
No
No
No
No
No
No
Yes
Describe how you would handle staff issues with poor performance or
conduct:
-
No
No
No
No
No
No
No
Yes
Describe your experience with managing and supervising staff from cultures
different than yours:
-
No
No
No
No
No
No
No
Yes
64
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
7.4 Mentoring Experience
Figure 7.4-a. Mentoring Experience Fields
65
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 7.4-a. Mentoring Experience Fields
Field Name
Does the Supervisor have
mentoring experience?
Years of Mentoring Experience:
Mentorship Experience (Select all
that apply):
Has the Supervisor had formal
mentoring training?
Values
1. Yes
2. No
1. I have mentored staff within my organization.
2. I have mentored fellows/associates in this
fellowship/program.
3. I have mentored fellows/associates in other
fellowships/programs.
1. Yes
2. No
EIS
No
LLS
No
EEP
Yes
FLIGHT
No
PMR/F
No
PHIFP
Yes
PE
No
PHAP
Yes
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
No
No
Yes
Yes
No
No
No
No
No
Yes
No
Yes
Describe the Supervisor's
mentoring experience:
-
No
No
No
No
No
Yes
No
Yes
Describe why the Supervisor
would be a good mentor/coach
for a fellow/associate and how
the primary supervisor will foster
growth and development:
-
No
No
No
No
No
Yes
No
Yes
66
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
8. Activities/Projects
8.1 Activity/Project Details
Figure 8.1-a. Activity/Project Details Fields
67
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 8.1-a. Activity/Project Details Fields
Field Name
Do you want to proceed?
Activity/Project Name:
Activity/Project Description:
Describe the data to be used:
Describe the methods:
Activity/Project Phase:
Topic Domains:
Specify Topic Domain:
Values
1. Conception
2. Initiation
3. Planning
4. Implementation
5. Evaluation
1. Informatics Evaluation
2. Problem Solving
3. Evaluation and Research Methods
4. Written & Oral Communication Skills
5. Stakeholder Engagement
6. Data Sciences
7. Data Science Methods
8. DataViz
9. Database design and development
10. Programming Languages and Scripting
11. Distributed Computing
12. Design Thinking
13. Systems Engineering
14. Project Management
15. Public Health Information Systems
16. Emerging Technologies
17. Systems and Strategic Thinking
18. Leadership & Innovation
19. Population Health Concepts
20. Other
-
EIS
No
No
No
No
No
No
LLS
No
No
No
No
No
No
EEP
No
No
No
No
No
No
FLIGHT
No
No
No
No
No
No
PMR/F
Yes
Yes
Yes
No
No
Yes
PHIFP
Yes
Yes
Yes
No
No
Yes
PE
Yes
Yes
Yes
Yes
Yes
Yes
PHAP
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
68
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Figure 8.1-b. Activity/Project Details Fields
Table 8.1-b. Activity/Project Details Fields
Field Name
Level of Responsibility / Role:
Specify Responsibility / Role:
Project Start Date:
Project End Date:
Describe the Public Health problems to be addressed by the
fellow/associate:
Describe the required skills the fellow must
have/contribute:
Values
1. Team Member
2. Coordinator
3. Lead
4. Other
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
Yes
PHIFP
Yes
PE
Yes
PHAP
Yes
-
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
-
No
No
No
No
No
No
Yes
No
69
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
8.2 Activity/Project Location
Figure 8.2-a. Activity/Project Location Fields
Table 8.2-a. Activity/Project Location Fields
Field Name
Is the Project/Activity address different from the
assignment address?
Activity/Project Address:
Values
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
Yes
PE
No
PHAP
Yes
-
No
No
No
No
No
Yes
No
Yes
1. Yes
2. No
70
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
8.3 Activity & Deliverable Details
Figure 8.3-a. Activity & Deliverable Details Fields
Table 8.3-a. Activity & Deliverable Details Fields
Field Name
Activities & Deliverables:
What are the expected products or deliverables of the
project? (Select all that apply):
Values
1. Manuscript
2. Presentation
3. Consultancy
4. Report
EIS
No
No
LLS
No
No
EEP
No
No
FLIGHT
No
No
PMR/F
Yes
No
PHIFP
Yes
No
PE
Yes
Yes
PHAP
Yes
No
71
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
8.4 Competencies
8.4.1 PHIFP
Figure 8.4.1-a. PHIFP Competencies Fields
Figure 8.4.1-b. PHIFP Competencies Fields
72
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 8.4.1-a. PHIFP Competencies Fields
Field Name
Select Domain 1 Competencies (See list above):
Values
1. 1.1
2. 1.2
3. 1.3
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
Yes
PE
No
PHAP
No
******
Select Domain 2 Competencies (See list above):
1. None of the above
1. 2.1
2. 2.2
3. 2.3
4. 2.4
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
******
Select Domain 3 Competencies (See list above):
1. None of the above
1. 3.1
2. 3.2
3. 3.3
4. 3.4
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
******
Select Domain 4 Competencies (See list above):
1. None of the above
1. 4.1
2. 4.2
3. 4.3
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
******
1. None of the above
No
No
No
No
No
Yes
No
No
73
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
8.4.2 PHAP
Figure 8.4.2-a. PHAP Competencies Fields
Figure 8.4.2-b. PHAP Competencies Fields
74
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 8.4.2-a. PHAP Competencies Fields
Field Name
1.0 Analytic and Assessment (See list above):
Values
1. 1.1
2. 1.2
3. 1.3
4. 1.4
5. 1.5
6. 1.6
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
******
2.0 Public Health Science (See list above):
1. None of the above
1. 2.1
2. 2.2
3. 2.3
4. 2.4
5. 2.5
6. 2.6
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
3.0 Program Planning, Management, and Improvement
(See list above):
1. None of the above
1. 3.1
2. 3.2
3. 3.3
4. 3.4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
4.0 Public Health Policy and Law (See list above):
1. None of the above
1. 4.1
2. 4.2
3. 4.3
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
1. None of the above
No
No
No
No
No
No
No
Yes
75
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Figure 8.4.2-c. PHAP Competencies Fields
Figure 8.4.2-d. PHAP Competencies Fields
76
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 8.4.2-b. PHAP Competencies Fields
Field Name
5.0 Professionalism (See list above):
Values
1. 5.1
2. 5.2
3. 5.3
4. 5.4
5. 5.5
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
******
6.0 Communication (See list above):
1. None of the above
1. 6.1
2. 6.2
3. 6.3
4. 6.4
5. 6.5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
7.0 Cultural Competency (See list above):
1. None of the above
1. 7.1
2. 7.2
3. 7.3
4. 7.4
5. 7.5
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
8.0 Community Dimensions of Public Health (See list
above):
1. None of the above
1. 8.1
2. 8.2
3. 8.3
4. 8.4
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
******
1. None of the above
No
No
No
No
No
No
No
Yes
77
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Figure 8.4.2-e. PHAP Competencies Fields
Table 8.4.2-c. PHAP Competencies Fields
Field Name
9.0 Financial Planning and Management (See list above):
******
Values
1. 9.1
2. 9.2
3. 9.3
4. 9.4
1. None of the above
EIS
No
LLS
No
EEP
No
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
Yes
No
No
No
No
No
No
No
Yes
78
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
9. Training & Languages
9.1 PHAP
Figure 9.-a. Training & Language Fields
Figure 9.-b. Training & Language Fields
79
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 9.-a. Training & Language Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Training Name/Subject:
Training Type:
1. One-on-One
2. E-learning
3. Classroom: HD
4. Classroom: Outside Sponsor
5. E-Learning CDC
6. Other
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Specify:
Brief Description:
Relation to proposed activity:
Date of Training:
Target Completion Date:
Language:
Fluency:
Language Lookup
1. Fluent (proficient in speaking,
reading and writing)
2. Conversational Only
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
80
Attachment 5 – FMS Host Site Module
10.
Student Rotation Preferences
10.1
EEP
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Figure 10.-a. Student Rotation Preference Fields
81
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Table 10.-a. Student Rotation Preference Fields
Field Name
Values
EIS
LLS
EEP
FLIGHT
PMR/F
PHIFP
PE
PHAP
Which type of student would you like to host?
1. Medical Student
2. Veterinarian Student
3. No Preference
No
No
Yes
No
No
No
No
No
Student Position Rotation Preference:
Rotation A: DD/MM/YY – DD/MM/YY
No
No
Yes
No
No
No
No
No
Rotation B: DD/MM/YY – DD/MM/YY
Rotation C: DD/MM/YY – DD/MM/YY
Rotation D: DD/MM/YY – DD/MM/YY
82
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
11.
Match
11.1
Match or Prematch Rank/Rating Form
Figure 11.-a. Match or Prematch Rank/Rating Fields
Table 11.-a. Match or Prematch Rank/Rating Fields
Field Name
Rank:
Post Match Rank:
Rating:
Comments:
This EEP Host Site:
Values
First Choice - Tenth Choice
First Choice - Tenth Choice
First Choice - Tenth Choice
1. Approves Student
2. Rejects Student
EIS
Yes
Yes
Yes
Yes
No
LLS
Yes
Yes
Yes
Yes
No
EEP
No
No
No
No
Yes
FLIGHT
Yes
Yes
Yes
Yes
No
PMR/F
Yes
Yes
Yes
Yes
No
PHIFP
Yes
Yes
Yes
Yes
No
PE
Yes
Yes
Yes
Yes
No
PHAP
No
No
No
No
No
83
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
11.2 Deferment
Table 11.2 Deferment
Field Name
REASON FOR DEFERMENT
Values
I can no longer participate.
Please explain or specify.
EIS
Yes
LLS
Yes
EEP
Yes
SAF
Yes
FLIGHT
No
PMR/F
No
PHIFP
No
PE
No
PHAP
No
84
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
2.Appendix
I. Field Value Tables
Appendix of Field Value Tables
Field Name
Approved Country
List
State/Territory
List
Application
Locations
6.5 Position
Assignment
Location
6.5 Position
Assignment
Location
Values
1
Values
2
United States
Anguilla
Antigua
Australia
Bahamas
Barbados
Barbuda
Belize
Bermuda
British Virgin Islands
Canada
Dominica
Grand Cayman Islands
Grenada
Guyana
Irish Republic
Jamaica
Montserrat
New Zealand
Saint Kitts and Nevis
St. Lucia
St. Vincent & the Grenadine
Tabago
Trinidad
Turks and Caicos Islands
United Kingdom
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington, DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Pacific Islands
U.S. Virgin Islands
Values
3
Values
4
85
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
CDC Fellowship
List
7.2 Supervisor
Information
AACN Fellowship
AAMC Public Health Policy Fellowship
Applied Public Health Informatics Fellowship (APHIF)
APTR Preventive Medicine and Public Health Fellowship
ASA/NCHS Research Fellowship Program
ASM Program in Infectious Disease and Public Health Microbiology
ASPH Allan Rosenfield Global Health Fellowship Program
ASPPH Public Health Fellowship Program
Biochemical Markers Fellowship
Collegiate Leaders in Environmental Health (CLEH)
CSTE Applied Epidemiology Fellowship Program
Dental Public Health Residency
DHPE Health Equity Fellowship Program
DHPE Internship Program for Public Health Practice Emory Rollins Earn and
Learn (REAL) Program
E-learning Institute (ELI)
Environmental Health Traineeship and Fellowship Program
Epidemic Intelligence Service (EIS)
Epidemiology Elective Program (EEP)
Evaluation Fellowship
Federal Work-Study Program (FWS)
Field Epidemiology Training Program (FETP)
Future Leaders in Infections and Global Health Threats (FLIGHT)
Future Public Health Leaders Program (FPHLP)
HACU National Internship Program (HNIP)
Health Systems Integration Program
Hubert Global Health Fellowship
Informatics Training in Place Program (I-TIPP)
International Emerging Infectious Diseases (IEID) Laboratory Fellowship Program
Internships and Externships in Public Health Law
James A Ferguson Emerging Infectious Diseases Fellowship
Junior Commissioned Officer Student Training and Extern Program (JRCOSTEP)
Laboratory Animal Medicine Residency Program (LAMRP)
Laboratory Leadership Service (LLS)
Maternal Child Health Careers/Research Initiatives for Student Enhancement –
Undergraduate Program (MCHC/RISE-UP)
Medical Toxicologist Fellowship Program
Morehouse College Project IHMOTEP Program
National Center for Health Statistics (NCHS) Academy Health Policy Fellowship
National Center for Health Statistics (NCHS) Postdoctoral Research Program
86
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
II. Lookup Tables
Appendix of Lookup Tables
Lookup Table Name
Fellowship Lookup
State/Territory Lookup
Application
Locations
3. eFMS System
Help Desk Ticket
5.3 Public Health
Agency Details
Values
1
CDC E-learning Institute
Fellowship Program (ELI)
CDC Steven M. Teutsch
Prevention Effectiveness (PE)
Fellowship
Epidemic Intelligence Service (EIS)
Epidemiology Elective Program
(EEP)
Future Leaders in Infections and
Global Health Threats (FLIGHT)
Laboratory Leadership Service
(LLS)
Population Health Training in
Place Program (PH-TIPP)
Population Health Workforce
Initiative (PHWI)
Preventive Medicine Residency
and Fellowship (PMR/F)
Public Health Associate Program
(PHAP)
Public Health Informatics
Fellowship Program (PHIFP)
Science Ambassador Fellowship
(SAF)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Washington, DC
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Values
2
Values
3
Values
4
Values
5
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Pacific Islands
87
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Public Health Agency
Lookup
5.3 Public Health
Agency Details
Missouri
Montana
Nebraska
U.S. Virgin Islands
Guam
Northern Mariana Islands
CDC Anchorage Quarantine
Station - Alaska
CDC Atlanta Quarantine Station Georgia
CDC Boston Quarantine Station Massachusetts
CDC Dallas/Ft. Worth Quarantine
Station - Texas
CDC Detroit Quarantine Station Michigan
CDC El Paso Quarantine Station Texas
CDC Honolulu Quarantine Station
- Hawaii
CDC Houston Quarantine Station
- Texas
CDC Los Angeles Quarantine
Station - California
CDC Miami Quarantine Station Florida
CDC Minneapolis Quarantine
Station - Minnesota
CDC Newark Quarantine Station New Jersey
CDC New York Quarantine Station
- New York
CDC Philadelphia Quarantine
Station - Pennsylvania
CDC San Diego Quarantine
Station - Florida
CDC San Francisco Quarantine
Station - California
CDC San Juan Quarantine Station
- Puerto Rico
CDC Seattle Quarantine Station Washington
CDC Washington Quarantine
Station - Washington, DC
Shoalwater Bay Health Clinic Washington
Marion County Health
Department - Oregon
Michigan Department of
Community Health - Michigan
Linn County Public Health
Department - Iowa
Prince William Health District Virginia
District 2: North Health District Georgia
Hillsborough County Health
Department - Florida
Palm Beach County Health
Department - Florida
American Samoa Dept of Health American Samoa
Guam Dept Pub Health & Soc
Serv - Guam
Edwardsville Regional
Office/Illinois Department of
Public Health - Illinois
Blackford County Health
Department - Indiana
Boone County Health
Department - Indiana
Brown County Health
Department - Indiana
Carroll County Health
Department - Indiana
Cass County Health
Department - Indiana
Clark County Health
Department - Indiana
Clay County Health
Department - Indiana
Fountain-Warren County
Health Department - Indiana
Clinton County Health
Department - Indiana
Crawford County Health
Department - Indiana
Franklin County Health
Department - Indiana
Daviess County Health
Department - Indiana
Fulton County Health
Department - Indiana
DeKalb County Health
Department - Indiana
Gary City Health Department
- Indiana
Dearborn County Health
Department - Indiana
Gibson County Health
Department - Indiana
Decatur County Health
Department - Indiana
Grant County Health
Department - Indiana
Delaware County Health
Department - Indiana
Greene County Health
Department - Indiana
Hamilton County Health
Department - Indiana
Dubois County Health
Department - Indiana
Lake County Health
Department - Indiana
East Chicago City Health
Department - Indiana
Hancock County Health
Department - Indiana
Elkhart County Health
Department - Indiana
Harrison County Health
Department - Indiana
Edgecombe County Health
Department - North Carolina
Clay County Health
Department - North Carolina
Cleveland County Health
Department - North Carolina
Forsyth County Department
of Public Health - North
Carolina
Columbus County Health
Department - North Carolina
Franklin County Health
Department - North Carolina
Craven County Health
Department - North Carolina
Gaston County Health
Department - North Carolina
Cumberland County Health
Department - North Carolina
Dare County Health
Department - North Carolina
Davidson County Health
Department - North Carolina
Granville-Vance District
Health Department - North
Carolina
Davie County Health
Department - North Carolina
Greene County Health
Department - North Carolina
Duplin County Health
Department - North Carolina
Guilford County Department
of Public Health - North
Carolina
Durham County Health
Department - North Carolina
Halifax County Department
of Health - North Carolina
Harnett County Health
Department - North Carolina
Haywood County Health
Department - North Carolina
Henderson County Health
Department - North Carolina
Hertford Health Department
- North Carolina
Hoke County Health Center North Carolina
Hyde County Health
Department - North Carolina
Iredell County Health
Department - North Carolina
Jackson County Department
of Public Health - North
Carolina
Johnston County Health
Department - North Carolina
Milam County Health
Department - Texas
Plano Environmental Health
Department - Texas
Montgomery County Public
Health Department - Texas
Orange County Health
Department - Texas
Port Arthur City Health
Department - Texas
Paris-Lamar County Health
Department - Texas
Richardson Health
Department - Texas
San Angelo-Tom Green
County Health Department Texas
San Antonio Metropolitan
Health District - Texas
Hays County Health
Department - Texas
San Patricio County
Department of Public Health Texas
Scurry County Health Unit Texas
South Plains Public Health
District - Texas
Sweetwater-Nolan County
Health Department - Texas
Texarkana-Bowie County
Health Department - Texas
Victoria City-County Health
Department - Texas
Northeast Texas Public
Health District - Texas
Waco-McLennan County
Public Health District - Texas
Uvalde County Health
Department - Texas
Wichita Falls-Wichita County
Public Health District - Texas
Williamson County and Cities
Health District - Texas
Wilson County Public Health
and Safety - Texas
Wood County Health
Department - Texas
Amarillo Bi-City County
Health District - Texas
Dallas County Health and
Human Services - Texas
Addison City Health
Department - Texas
Falfurrias City Health
Department - Texas
City of Baytown Health
Department - Texas
88
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Puerto Rico Departamento de
Salud - Puerto Rico
Virgin Islands Department of
Health - U.S. Virgin Islands
Rosebud Sioux Tribe - South
Dakota
Three Affiliated Tribes - North
Dakota
Lower Brule Sioux Tribe - South
Dakota
Spirit Lake Tribe - North Dakota
Sisseton-Wahpeton Oyate of the
Lake Traverse Reservation - South
Dakota
Trenton Indian Service Area North Dakota
Standing Rock Sioux Tribe - North
Dakota
Crow Creek Sioux Tribe - South
Dakota
Santee Sioux Nation - Nebraska
Cheyenne River Sioux Tribe South Dakota
Ponca Tribe of Nebraska Nebraska
Turtle Mountain Band of
Chippewa - North Dakota
Flandreau Santee Sioux Tribe South Dakota
Yankton Sioux Tribe - South
Dakota
Sac & Fox Tribe of the Mississippi
in Iowa - Iowa
Oglala Sioux Tribe - South Dakota
Winnebago Tribe of Nebraska Nebraska
Omaha Tribe of Nebraska Nebraska
Native Village of Tyonek - Alaska
Searhc Mt. Edgecumbe Hospital Alaska
Metlakatla Indian Community Alaska
Fairbanks Native Association Alaska
Alaska Native Tribal Health
Consortium - Alaska
Mount Sanford Tribal Consortium
- Alaska
Arctic Slope Native Association Alaska
Bristol Bay Area Health
Corporation - Alaska
Ukpeagvik Inupiat Corporation Alaska
Maniilaq Association - Alaska
Searhc Juneau Medical Center Alaska
Akiachak Native Community Alaska
Southcentral Foundation - Alaska
Chickaloon Native Village - Alaska
Fayette County Health
Department - Indiana
Hendricks County Health
Department - Indiana
Floyd County Health
Department - Indiana
Henry County Health
Department - Indiana
Howard County Health
Department - Indiana
Huntington County Health
Department - Indiana
Jackson County Health
Department - Indiana
Jasper County Health
Department - Indiana
Jay County Health Center Indiana
Miami County Health
Department - Indiana
Jefferson County Health
Department - Indiana
Jennings County Health
Department - Indiana
Monroe County Health
Department - Indiana
Johnson County Health
Department - Indiana
Montgomery County Health
Department - Indiana
Knox County Health
Department - Indiana
Morgan County Health
Department - Indiana
Kosciusko County Health
Department - Indiana
LaGrange County Health
Department - Indiana
Newton County Health
Department - Indiana
LaPorte County Health
Department - Indiana
Noble County Health
Department - Indiana
Lawrence County Health
Department - Indiana
Ohio County Health
Department - Indiana
Madison County Health
Department - Indiana
Orange County Health
Department - Indiana
Marion County Public Health
Department - Indiana
Owen County Health
Department - Indiana
Marshall County Health
Department - Indiana
Parke County Health
Department - Indiana
Perry County Health
Department - Indiana
Jones County Health
Department - North Carolina
Lee County Health
Department - North Carolina
Lenoir County Health
Department - North Carolina
Northampton County Health
Department - North Carolina
Lincoln County Health
Department - North Carolina
Macon County Public Health
Center - North Carolina
Onslow County Health
Department - North Carolina
Madison County Health
Department - North Carolina
Orange County Health
Department - North Carolina
Martin Tyrrell Washington
District - North Carolina
Pamlico County Health
Department - North Carolina
Mecklenburg County Health
Department - North Carolina
Pender County Health
Department - North Carolina
Montgomery County Health
Department - North Carolina
Person County Health
Department - North Carolina
Moore County Health
Department - North Carolina
Pitt County Public Health
Center - North Carolina
Nash County Health
Department - North Carolina
Randolph County Health
Department - North Carolina
New Hanover County Health
Department - North Carolina
Richmond County Health
Department - North Carolina
Robeson County Health
Department - North Carolina
Rockingham County Health
Department - North Carolina
Rowan County Health
Department - North Carolina
Rutherford-Polk-McDowell
District - North Carolina
Sampson County Health
Department - North Carolina
Scotland County Health
Department - North Carolina
Stanly County Health
Department - North Carolina
Stokes Family Health Center North Carolina
Surry County Health and
Nutrition Center - North
Carolina
Toe River District - North
Carolina
Allen City Environmental
Health Department - Texas
Health Department of
Gainseville - Texas
McCulloch County Health
Department - Texas
Mills County Judge - Texas
Hood County Health
Department - Texas
Burleson City Environmental
Health Department - Texas
Duncanville City Health
Department - Texas
Carrollton City Health
Department - Texas
Brooks County Welfare Clinic
- Texas
DeSoto City Health
Department - Texas
Gillespie County - Texas
Gainesville City Health
Department - Texas
Graham City Health
Department - Texas
Harlingen City Health
Department - Texas
Upper Guadalupe River
Authority - Texas
Fayette County Department
of Sanitation - Texas
Lewisville Health and Code
Enforcement - Texas
McAllen Health Department Texas
Lockhart City Health
Department - Texas
Luling City Health
Department - Texas
Pasadena Health Department
- Texas
Lampasas County Health
Department - Texas
Caldwell County Sanitation
Department - Texas
Madison County Courthouse
- Texas
Mineral Wells City Health
Department - Texas
North Richland Hills Health
Department - Texas
Parker County Health
Department - Texas
Texas Department of
Health/Region 7 - Texas
Guadalupe County
Environmental Health - Texas
Weatherford City Health
Department - Texas
Texas Department of
Health/Region 8 - Texas
Tarrant County Public Health
Department - Texas
89
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
SouthEast Alaska Regional Health
Consortium - Alaska
Valdez Native Tribe - Alaska
Alaska Native Medical Center Alaska
Tanana Chiefs Conference Alaska
North Slope Borough Health Corp
- Alaska
Chief Andrew Isaac Health Center
- Alaska
Ninilchik Traditional Council Alaska
Ketchikan Indian Corporation Alaska
Eastern Aleutian Tribes, Inc Alaska
Native Village of Kwinhagak Alaska
St. George Community Council Alaska
Cook Inlet Tribal Council, Inc. Alaska
Yukon-Kuskokwim Regional
Health Corporation - Alaska
Kenaitze Indian Tribe - Alaska
Aleutian Pribilof Islands
Association, Inc. - Alaska
Norton Sound Health Corporation
- Alaska
Copper River Native Association Alaska
Council of Athabascan Tribal
Governments - Alaska
Tanana Tribal Council - Alaska
Kodiak Area Native Association Alaska
Towaoc PHS Indian Health Center
- Colorado
Santa Fe PHS Indian Hospital New Mexico
Isleta Health Center - New
Mexico
Santa Clara PHS Indian Hlth Ctr New Mexico
Tribal Human Services - New
Mexico
Zuni Health Program - New
Mexico
San Ildefonso Pueblo Health
Program - New Mexico
Alamo Navajo School Board New Mexico
Ysleta del Sur Pueblo - Texas
Zia Pueblo Health Program - New
Mexico
Ramah Navajo School Board, Inc.
- New Mexico
Kewa Pueblo Health Program New Mexico
Ignacio PHS Indian Health Center
- Colorado
Martin County Health
Department - Indiana
Pike County Health
Department - Indiana
Porter County Health
Department - Indiana
Posey County Health
Department - Indiana
Pulaski County Health
Department - Indiana
Putnam County Health
Department - Indiana
Randolph County Health
Department - Indiana
Vanderburgh County Health
Department - Indiana
Ripley County Health
Department - Indiana
Rush County Health
Department - Indiana
Vermillion County Health
Department - Indiana
Scott County Health
Department - Indiana
Vigo County Health
Department - Indiana
Wabash County Health
Department - Indiana
Shelby County Health
Department - Indiana
Warrick County Health
Department - Indiana
Spencer County Health
Department - Indiana
Washington County Health
Department - Indiana
St. Joseph County Health
Department - Indiana
Wayne County Health
Department - Indiana
Starke County Health
Department - Indiana
Wells County Health
Department - Indiana
Steuben County Health
Department - Indiana
Sullivan County Health
Department - Indiana
White County Health
Department - Indiana
Whitley County Health
Department - Indiana
Switzerland County Health
Department - Indiana
Barber County Public Health
Department - Kansas
Tippecanoe County Health
Department - Indiana
Barton County Health
Department - Kansas
Tipton County Health
Department - Indiana
Transylvania County Health
Department - North Carolina
Union County Health
Department - North Carolina
Bismarck-Burleigh Public
Health - North Dakota
Wake County Human
Services - North Carolina
Warren County Health
Department - North Carolina
Central Valley Health District
- North Dakota
Wayne County Health
Department - North Carolina
City-County Health District North Dakota
Wilson County Department
of Pubic Health - North
Carolina
Custer District Health Unit North Dakota
Yadkin County Health
Department - North Carolina
Emmons County Public
Health - North Dakota
Caswell County Health
Department - North Carolina
Fargo/Cass Public Health North Dakota
Swain County Health
Department - North Carolina
First District Health Unit North Dakota
Graham County Health
Department - North Carolina
Foster County Community
Health Department - North
Dakota
Albemarle Regional Health
Services - North Carolina
Grand Forks City County
Public Health Department North Dakota
Kidder District Health Unit North Dakota
Lake Region District Health
Unit - North Dakota
McIntosh District Health Unit
- North Dakota
Nelson-Griggs District Health
Unit - North Dakota
Pembina County Health
Department - North Dakota
Ransom County Public Health
- North Dakota
Richland County Health
Department - North Dakota
Sargent County District
Health Unit - North Dakota
Southwestern District Health
Unit - North Dakota
Steele County Public Health North Dakota
Texas Department of
Health/Regions 9 and 10 Texas
Texas Department of
Health/Region 1 - Texas
Texas Department of
Health/Region 11 - Texas
Texas Department of
Health/Regions 2 and 3 Texas
Willacy County Health
Department - Texas
Texas Department of
Health/Regions 4 and 5 North
- Texas
City of South Padre Island
Health Department - Texas
Texas Department of
Health/Regions 6 and 5 South
- Texas
Brownsville Health
Department - Texas
City of Longview Health
Department - Texas
Public Health/Sheppard Air
Force Base - Texas
Bear River Health
Department - Utah
Central Utah Public Health
Department - Utah
Utah County Health
Department - Utah
Davis County Department of
Health - Utah
Southeastern Utah District
Health Department - Utah
Southwest Utah Public Health
Department - Utah
Salt Lake Valley Health
Department - Utah
Summit County Public Health
Department - Utah
Tooele County Health
Department - Utah
Tri-County Health
Department - Utah
Wasatch County Health
Department - Utah
Weber-Morgan Health
Department - Utah
Eastern Shore Health District
- Virginia
Bath County Health
Department - Virginia
Albemarle/Charlottesville
Health Department - Virginia
Alexandria Health
Department/Alexandria
Health District - Virginia
Bedford County Health
Department - Virginia
Alleghany County / Covington
Health Department - Virginia
90
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Pine Hill Indian Health Center New Mexico
Alamo Navajo Health Station New Mexico
Jicarilla Apache Tribe - New
Mexico
San Juan Pueblo Health Program New Mexico
Santa Ana Pueblo Health Program
- New Mexico
Five Sandoval Indian Pueblos, Inc.
- New Mexico
Eight Northern Indian Pueblos,
Inc. Hlth Prog. - New Mexico
Southern Ute Health Program Colorado
Jemez Dept of Health & Human
Svcs - New Mexico
San Felipe Health Program - New
Mexico
Santa Ana Health Clinic - New
Mexico
Zia Health Clinic - New Mexico
Santa Clara Pueblo Health
Program - New Mexico
Taos CHR Program - New Mexico
Tesuque Pueblo Health Program New Mexico
Ute Mountain Ute Health
Program - Colorado
Sandia Health Program - New
Mexico
Red Lake Comprehensive Hlth Svc
- Minnesota
Bad River Health Services Wisconsin
Ho-Chunk Nation Health Dept Wisconsin
Little River Band of Ottawa
Indians - Michigan
Grand Traverse Ottawa &
Chippewa - Michigan
Sault Ste. Marie HHS - Michigan
Oneida Community Health Center
- Wisconsin
Match-E-Be-Nash-She-Wish
Pottawatomi - Michigan
Red Cliff Health Services Wisconsin
Lac Courte Oreilles Comm Hlth
Ctr - Wisconsin
White Earth Band Health Division
- Minnesota
Lac Vieux Desert Band - Michigan
Minnesota Chippewa Tribe Minnesota
Bois Forte Tribal Clinic Minnesota
Inter-Tribal Council of Michigan,
Inc. - Michigan
Potawatomi Health & Wellness
Center - Wisconsin
Butler County Health
Department - Kansas
Union County Health
Department - Indiana
Chase County Health
Department - Kansas
Chautauqua Health
Department - Kansas
Cherokee County Health
Department - Kansas
Ellsworth County Health
Department - Kansas
Cheyenne County Health
Department - Kansas
Clark County Health
Department - Kansas
Finney County Health
Department - Kansas
Clay County Health
Department - Kansas
Ford County Health
Department - Kansas
Cloud County Health
Department - Kansas
Franklin County Health
Department - Kansas
Coffey County Health
Department - Kansas
Gove County Health
Department - Kansas
Comanche County Health
Department - Kansas
Graham County Health
Department - Kansas
City-Cowley County Health
Department - Kansas
Grant County Health
Department - Kansas
Crawford County Health
Department - Kansas
Gray County Health
Department - Kansas
Decatur Health Department Kansas
Greeley County Health
Department - Kansas
Dickinson County Health
Department - Kansas
Hamilton County Health
Department - Kansas
Doniphan County Health
Department - Kansas
Harper County Health
Department and Home
Health Agency - Kansas
Edwards County Health
Department - Kansas
Harvey County Health
Department - Kansas
Elk County Health
Department - Kansas
Hodgeman County Health
Department - Kansas
Traill District Health Unit North Dakota
Upper Missouri District
Health Unit - North Dakota
Three Affiliated Tribes Minne Tohe Health Center North Dakota
Walsh County Health
Department - North Dakota
Wells County District Health
Unit - North Dakota
Trenton Indian Service Area Trenton Community Clinic North Dakota
Cavalier County Health
District - North Dakota
Turtle Mountain Chippewa North Dakota
Dickey County Health District
- North Dakota
Clay County Health
Department - Nebraska
Rolette County Public Health
District - North Dakota
Dakota County Health
Department - Nebraska
Towner County Public Health
District - North Dakota
Douglas County Health
Department - Nebraska
LaMoure County Public
Health Department - North
Dakota
Central District Health
Department - Nebraska
Spirit Lake Tribal Health
Program - North Dakota
Elkhorn Logan Valley Health
Department - Nebraska
Standing Rock Tribal Health North Dakota
Lincoln-Lancaster County
Health Department Nebraska
Southeast District Health
Department - Nebraska
Four Corners Health
Department - Nebraska
Polk County Health
Department - Nebraska
Red Willow County Health
Department - Nebraska
Sandhills District Health
Department - Nebraska
Three Rivers District Health
Department - Nebraska
Scotts Bluff County Health
Department - Nebraska
South Heartland District
Health Department Nebraska
East Central District Health
Department - Nebraska
Bland County Health
Department - Virginia
Amelia County Health
Department - Virginia
Alleghany Health District Virginia
Amherst County Health
Department - Virginia
Bristol City Health
Department - Virginia
Appomattox County Health
Department - Virginia
Brunswick County Health
Department - Virginia
Buchanan County Health
Department - Virginia
Arlington Health District Virginia
Buckingham County Health
Department - Virginia
Augusta-Staunton Health
Department - Virginia
Buena Vista City Health
Department - Virginia
Campbell County Health
Department - Virginia
Caroline County Health
Department - Virginia
Carroll County Health
Department - Virginia
Charles City County Health
Department - Virginia
Charlotte County Health
Department - Virginia
Chesapeake Health District Virginia
Chesterfield Health District Virginia
Clarke County Health
Department - Virginia
Clifton Forge City Health
Department - Virginia
Colonial Heights City Health
Department - Virginia
Craig County Health
Department - Virginia
Cumberland Plateau Health
District - Virginia
Fredericksburg City Health
Department - Virginia
Danville City Health
Department - Virginia
Galax City Health Department
- Virginia
Dickenson County Health
Department - Virginia
Chickahominy Health District
- Virginia
Dinwiddie County Health
Department - Virginia
Gloucester County Health
Department - Virginia
91
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Leech Lake Band of Chippewa
Indians - Minnesota
Ellen Marshall Memorial Center Michigan
Keweenaw Bay Indian
Community - Michigan
Shakopee Mdewakanton
Business Council - Minnesota
Huron Potawatomi, Inc. Michigan
Prairie Island Family Health Clinic
- Minnesota
Hannahville Health Center Michigan
Stockbridge-Munsee Tribal
Health Center - Wisconsin
St. Croix Tribal Health Dept. Wisconsin
Fond du Lac Min-No-Aya-Win
Clinic - Minnesota
Nimkee Memorial Wellness
Center - Michigan
Pokagon Potawatomi Health
Services - Michigan
Grand Portage Band Tribal Office
- Minnesota
Mille Lacs Band Ne-Ia-Shing Clinic
- Minnesota
Great Lake Inter-Tribal Council Wisconsin
Lac du Flambeau - Pete
Christensen Hlth Ctr - Wisconsin
Lower Sioux Community Council Minnesota
Little Traverse Bay Band of
Odawa - Michigan
Upper Sioux Community Minnesota
Sokaogon Chippewa Indian
Community - Wisconsin
Menominee Tribal Clinic Wisconsin
Arapaho Clinic - Wyoming
Wolf Point Clinic - Montana
Lodge Grass Clinic - Montana
Heart Butte Clinic - Montana
Hays Clinic - Montana
Fort Belknap Tribal Health Dept. Montana
Flathead Tribal Hlth & Human
Svcs Dept. - Montana
Crow Tribal Health Department Montana
Fort Peck Tribal Health Project Montana
Northern Cheyenne Tribal Health
Dept. - Montana
Northern Arapaho Tribal Health
Dept. - Wyoming
Shoshone Tribal Health
Department - Wyoming
Rocky Boy Tribal Health Dept. Montana
Ellis County Health
Department - Kansas
Jefferson County Health
Department - Kansas
Jewell County Health
Department - Kansas
Johnson County Public
Health - Kansas
McPherson County Health
Department - Kansas
Junction City Geary County
Health Department - Kansas
Meade County Health
Department - Kansas
Kearny County Health
Department - Kansas
Kingman County Health
Department - Kansas
Miami County Health
Department - Kansas
Kiowa County Health
Department - Kansas
Mitchell County Health
Department - Kansas
Labette County Health
Department - Kansas
Montgomery County Health
Department - Kansas
Lane County Health
Department - Kansas
Morris County Health
Department - Kansas
Lawrence-Douglas County
Health Department - Kansas
Morton County Health
Department - Kansas
Leavenworth County Health
Department - Kansas
NEK Multi-County Health
Department - Kansas
Seward County Health
Department - Kansas
Nemaha County Community
Health Services - Kansas
Lincoln County Health
Department - Kansas
Neosho County Health
Department - Kansas
Logan County Health
Department - Kansas
Ness County Health
Department - Kansas
Lyon County Health
Dept./Flint Hills Community
Health Center - Kansas
Norton County Health
Department - Kansas
Marion County Health
Department - Kansas
Osage County Health
Department - Kansas
Marshall County Health
Department - Kansas
Northeast Nebraska Public
Health Department Nebraska
Loup Basin Public Health
Department - Nebraska
North Central District Health
Department (NCDHD) Nebraska
Claremont Health
Department - New
Hampshire
Panhandle Public Health
District - Nebraska
Public Health Solutions
District Health Department Nebraska
Concord Health Department New Hampshire
Sarpy/Cass Department of
Health and Wellness Nebraska
Derry Health Department New Hampshire
Southwest Nebraska Public
Health Department Nebraska
Dover Health Department New Hampshire
Two Rivers Public Health
Department - Nebraska
Keene Health Department New Hampshire
West Central District Health
Department - Nebraska
Manchester Health
Department - New
Hampshire
Winnebago Tribe of Nebraska
Health Dept - Nebraska
Merrimack Health
Department - New
Hampshire
Amherst Health Department New Hampshire
Nashua Division of Public
Health and Community
Services - New Hampshire
Berlin Health Department New Hampshire
Plaistow Health Department New Hampshire
Portsmouth Health
Department - New
Hampshire
Salem Health Department New Hampshire
Somersworth Health
Department - New
Hampshire
Lebanon Health Department New Hampshire
Acworth Health Department New Hampshire
Fairfax County Health
Department - Virginia
Goochland County Health
Department - Virginia
Fauquier County Health
Department - Virginia
Grayson County Health
Department - Virginia
Floyd County Health
Department - Virginia
Greene County Health
Department - Virginia
Fluvanna County Health
Department - Virginia
Isle of Wight County Health
Department - Virginia
Franklin City Health
Department - Virginia
Halifax County Health
Department - Virginia
Frederick County/Winchester
Health Department - Virginia
Hampton City Health District
- Virginia
King William County Health
Department - Virginia
Lancaster County Health
Department - Virginia
Lee County Health
Department - Virginia
Loudoun County Health
District - Virginia
Louisa County Health
Department - Virginia
Lunenburg County Health
Department - Virginia
Lynchburg City Health
Department - Virginia
Madison County Health
Department - Virginia
Mathews County Health
Department - Virginia
Petersburg City Health
Department - Virginia
Mecklenburg County Health
Department - Virginia
Pittsylvania/Danville Health
District - Virginia
Middlesex County Health
Department - Virginia
Portsmouth Health District Virginia
New River Health District Virginia
Powhatan County Health
Department - Virginia
Nelson County Health
Department - Virginia
Prince Edward County Health
Department - Virginia
New Kent County Health
Department - Virginia
92
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Blackfeet Tribal Health
Department - Montana
Lone Pine Indian Health Clinic California
Table Mountain Rancheria California
Cabazon Band of Mission Indians
- California
Colusa Indian Community Council
- California
Greenville Rancheria of Maidu
Indians - California
Tule River Indian Health Center,
Inc. - California
Cold Springs Rancheria of Mono
Indians - California
Shingle Springs Tribal Health
Programs - California
Hopland Band of Pomo Indians California
Susanville Indian Health Center California
Chapa-De Indian Health Program,
Inc. - California
Sycuan Band of the Kumeyaay
Nation - California
Sherwood Valley Band of Pomo
Indians - California
Central Valley Indian Health, Inc. California
Santa Rosa Rancheria - California
Consolidated Tribal Health
Project, Inc. - California
Guidiville Indian Rancheria California
Soboba Indian Health Clinic California
Indian Health Center of Santa
Clara Valley - California
Feather River Tribal Health Inc. California
Southern Indian Health Council California
Tuolumne Me-Wuk Indian Hlth
Ctr - California
Northern Valley Indian Health California
Toiyabe Indian Health Project California
Indian Health Council, Inc. California
Sonoma County Indian Health
(CRIHB) - California
Coyote Valley Tribal Council California
Lytton Rancheria - California
Santa Ynez Band of Chumash
Mission Indians - California
Lake County Tribal Health
Consortium - California
Quartz Valley Indian Reservation California
Osborne County Health
Department - Kansas
Ottawa County Health
Department/Hospice Kansas
Pawnee County Health
Department - Kansas
Sheridan County Public
Health Department - Kansas
Phillips County Health
Department - Kansas
Pottawatomie County Health
Department - Kansas
Sherman County Health
Department - Kansas
Pratt County Health
Department - Kansas
Rawlins County Health
Department - Kansas
Smith County Health
Department - Kansas
Reno County Health
Department - Kansas
Stafford County Health
Department - Kansas
Republic County Health
Department - Kansas
Stanton County Health
Department - Kansas
Rice County Health
Department - Kansas
Riley County-Manhattan
Health Department - Kansas
Sumner County Health
Department - Kansas
Rooks County Health
Department - Kansas
Thomas County Health
Department - Kansas
Rush County Health
Department - Kansas
Shawnee County Health
Agency - Kansas
Russell County Health
Department - Kansas
Trego County Health
Department - Kansas
Allen SEK Multi-County
Health Department - Kansas
Wabaunsee County Health
Department - Kansas
Salina-Saline County Health
Department - Kansas
Wallace County Health
Department - Kansas
Scott County Health
Department - Kansas
Washington County Health
Department - Kansas
Wichita County Health
Department - Kansas
Sedgwick County Health
Department - Kansas
Albany Health Department New Hampshire
Alexandria Health
Department - New
Hampshire
Allenstown Health
Department - New
Hampshire
Alstead Health Department New Hampshire
Alton Health Department New Hampshire
Andover Health Department New Hampshire
Bethlehem Health
Department - New
Hampshire
Antrim Health Department New Hampshire
Ashland Health Department New Hampshire
Bow Health Department New Hampshire
Atkinson Health Department
- New Hampshire
Bradford Health Department
- New Hampshire
Auburn Health Department New Hampshire
Brentwood Health
Department - New
Hampshire
Barnstead Health
Department - New
Hampshire
Bridgewater Health
Department - New
Hampshire
Barrington Health
Department - New
Hampshire
Bristol Health Department New Hampshire
Bartlett Health Department New Hampshire
Brookfield Health
Department - New
Hampshire
Belmont Health Department New Hampshire
Brookline Health Department
- New Hampshire
Bennington Health
Department - New
Hampshire
Campton Health Department
- New Hampshire
Benton Health Department New Hampshire
Canaan Health Department New Hampshire
Candia Health Department New Hampshire
Prince George County Health
Department - Virginia
Norfolk City Health District Virginia
Prince William Health District
- Virginia
Lord Fairfax Health District Virginia
Rappahannock Health District
- Virginia
Northumberland County
Health Department - Virginia
Rappahannock/Rapidan
Health District - Virginia
Nottoway County Health
Department - Virginia
Richmond City Health
Department - Virginia
Orange County Health
Department - Virginia
Richmond County Health
Department - Virginia
Page County Health
Department - Virginia
Roanoke County/Salem
Health Department - Virginia
Roanoke County/Vinton
Health Department - Virginia
Rockbridge/Lexington Health
Department - Virginia
Rockingham/Harrisonburg
Health Department - Virginia
Russell County Health
Department - Virginia
Scott County Health
Department - Virginia
Shenandoah County Health
Department - Virginia
Westmoreland County Health
Department - Virginia
Smyth County Health
Department - Virginia
South Hampton County
Health Department - Virginia
Peninsula Health District Virginia
Spotsylvania County Health
Department - Virginia
Wise/Norton Health
Department - Virginia
Stafford County Health
Department - Virginia
Wythe County Health
Department - Virginia
Western Tidewater Health
District - Virginia
York/Denbigh Health
Department - Virginia
Surry County Health
Department - Virginia
Three Rivers Health District Virginia
93
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Sierra Tribal Consortium California
M.A.C.T. Health Board, Inc. California
Mashpee Wampanoag Tribe Massachusetts
Round Valley Indian Health
Center - California
Warner Mountain Indian Hlth
Project - California
Oneida Nation of NY Health
Program - New York
Tunica-Biloxi Indian Tribe of
Louisiana - Louisiana
Karuk Tribe - California
Mohegan Tribe of Indians of CT Connecticut
United Indian Health Services California
Penobscot Nation Health
Department - Maine
Redding Rancheria Health Clinic California
St. Regis Mohawk Health Services
- New York
Hoopa Valley Tribe - California
Narragansett Indian Tribe Health
Program - Rhode Island
Pinoleville Band of Pomo Indians California
Houlton Band of Maliseet Indians
Hlth Dept - Maine
Pit River Health Services, Inc. California
Lionel R. John Health Center New York
Scotts Valley Band of Pomo
Indians - California
Passamaquoddy Indian Township
Hlth Ctr - Maine
National Indian Education
Association - Washington, DC
Miccosukee Tribe of Indians of
Florida - Florida
Cattaraugus Indian Reservation
Hlth Ctr - New York
Aroostook Band of Micmac
Indians - Maine
Miami Nation of Indiana - Indiana
Chitimacha Tribe of Louisiana Louisiana
Catawba Indian Nation - South
Carolina
Poarch Band of Creek Indians Alabama
Wampanoag Tribe of Gay Head Massachusetts
UNITY Healing Center - North
Carolina
Tohatchi PHS Indian Health
Center - New Mexico
Alabama-Coushatta Tribe of
Texas - Texas
Wilson County Health
Department - Kansas
Unified Government of
Wyandotte County Public
Health Department - Kansas
Haskell County Health
Department - Kansas
Anderson SEK-Multi County
Health Department - Kansas
West Central Public Health
Initiative - Kansas
Atchison NEK-Multi County
Health Department - Kansas
Bourbon SEK-Multi County
Health Department - Kansas
Sumner County PlanningZoning-Environmental
Health - Kansas
Jackson NEK-Multi County
Health Department - Kansas
Anderson County Health
Department - Kentucky
Linn County Health
Department - Kansas
Barren River District Health
Department - Kentucky
Woodson SEK-Multi County
Health Department - Kansas
Bourbon County Health
Department - Kentucky
Stevens County Health
Department - Kansas
Boyle County Health
Department - Kentucky
Northwest District
Office/KDHE - Kansas
Breathitt County Health
Department - Kentucky
Southwest District
Office/KDHE - Kansas
Buffalo Trace District Health
Department - Kentucky
North Central District
Office/KDHE - Kansas
Bullitt County Health
Department - Kentucky
South Central District
Office/KDHE - Kansas
Christian County Health
Department - Kentucky
Northeast District
Office/KDHE - Kansas
Clark County Health
Department - Kentucky
Southeast District
Office/KDHE - Kansas
Cumberland Valley District
Health Department Kentucky
Estill County Health
Department - Kentucky
Ashland-Boyd County Health
Department - Kentucky
Canterbury Health
Department - New
Hampshire
Carroll Health Department New Hampshire
Center Harbor Health
Department - New
Hampshire
Charlestown Health
Department - New
Hampshire
Chatham Health Department
- New Hampshire
Chester Health Department New Hampshire
Chesterfield Health
Department - New
Hampshire
Chichester Health
Department - New
Hampshire
Clarksville Health
Department - New
Hampshire
Colebrook Health
Department - New
Hampshire
Columbia Health Department
- New Hampshire
Dorchester Health
Department - New
Hampshire
Conway Health Department New Hampshire
Cornish Health Department New Hampshire
Dublin Health Department New Hampshire
Croydon Health Department New Hampshire
Dummer Health Department
- New Hampshire
Dunbarton Health
Department - New
Hampshire
Dalton Health Department New Hampshire
Durham Health Department New Hampshire
Danbury Health Department New Hampshire
East Kingston Health
Department - New
Hampshire
Danville Health Department New Hampshire
Easton Health Department New Hampshire
Deerfield Health Department
- New Hampshire
Eaton Health Department New Hampshire
Sussex County Health
Department - Virginia
Southside Health District Virginia
Tazewell County Health
Department - Virginia
Henrico Health District Virginia
Virginia Beach City Health
District - Virginia
Henry/Martinsville Health
Department - Virginia
Warren County Health
Department - Virginia
Highland County Health
Department - Virginia
Washington County Health
Department - Virginia
Hopewell City Health
Department - Virginia
Waynesboro City Health
Department - Virginia
Greensville/Emporia Health
Department - Virginia
King and Queen County
Health Department - Virginia
King George County Health
Department - Virginia
Pulaski County Health
Department - Virginia
Roanoke City Health District Virginia
Central Shenandoah Health
District - Virginia
Central Virginia Health
District - Virginia
Cumberland County Health
Department - Virginia
Crater Health District Virginia
Lenowisco Health District Virginia
Pittsylvania County Health
Department - Virginia
Mount Rogers Health District
- Virginia
Culpeper County Health
Department - Virginia
Piedmont Health District Virginia
Rappahannock County Health
Department - Virginia
Thomas Jefferson Health
District - Virginia
Essex County Health
Department - Virginia
Suffolk City Health
Department - Virginia
West Piedmont Health
District - Virginia
Bennington Vermont
Department of Health Vermont
94
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Mashantucket Pequot Health
Dept - Connecticut
Winslow Indian Hlth. Care Ctr.,
Inc. - Arizona
Jena Band of Choctaw Indians Louisiana
Navajo Division of Social Services
- Arizona
Coushatta Tribe of Louisiana Louisiana
Navajo Division of Health Arizona
Choctaw Health Center Mississippi
Utah Navajo Hlth System, Inc. Utah
Big Cypress IHS Center - Florida
Navajo Division of EMS - Arizona
Brighton Health Center - Florida
Inscription House Health Center Arizona
Seminole Tribe of FL - Hth.
Admin. - Florida
Passamaquoddy Pleasant Point
Hlth Center - Maine
Pawhuska PHS Indian Hlth Ctr Oklahoma
Dzilth-Na-O-Dith-Hle-PHS Indian
Hlth Ctr - New Mexico
Sapulpa Health Center Oklahoma
San Juan Southern Paiute Tribe Arizona
Carnegie Indian Health Center Oklahoma
Health & Social Svcs Committee Arizona
Fort Sill Apache Tribe - Oklahoma
Tsaile PHS Indian Health Center Arizona
Sac & Fox Nation of Missouri Kansas
Tuba City Regional Hlth Care
Corp. - Arizona
Eufaula Health Center - Oklahoma
Osage Nation - Oklahoma
Choctaw Nation of Oklahoma Oklahoma
Ardmore Chickasaw Health Clinic
- Oklahoma
Choctaw Nation Health Care
Center - Oklahoma
Kickapoo Traditional Tribe of
Texas - Texas
Kickapoo Tribe in Kansas - Kansas
Otoe-Missouria Tribe - Oklahoma
Cherokee Nation of Oklahoma Oklahoma
El Reno PHS Indian Hlth Clinic Oklahoma
Citizen Potawatomi Nation Hlth
Clinic - Oklahoma
Kanza Health Clinic - Oklahoma
Fleming County Health
Department - Kentucky
Floyd County Health
Department - Kentucky
Franklin County Health
Department - Kentucky
Lincoln Trail District Health
Department - Kentucky
Gateway District Health
Department - Kentucky
Green River District Health
Department - Kentucky
Little Sandy District Health
Department - Kentucky
Greenup County Health
Department - Kentucky
Louisville Metro Department
of Public Health and
Wellness - Kentucky
Hopkins County Health
Department - Kentucky
Madison County Health
Department - Kentucky
Jessamine County Health
Department - Kentucky
Magoffin County Health
Department - Kentucky
Johnson County Health
Department - Kentucky
Marshall County Health
Department - Kentucky
Kentucky River District
Health Department Kentucky
Martin County Health
Department - Kentucky
Knox County Health
Department - Kentucky
Monroe County Health
Department - Kentucky
Lake Cumberland District
Health Department Kentucky
Muhlenberg County Health
Department - Kentucky
Laurel County Health
Department - Kentucky
North Central District Health
Department - Kentucky
Lewis County Health
Department - Kentucky
Northern Kentucky
Independent District Health
Department - Kentucky
Lexington-Fayette County
Health Department Kentucky
Oldham County Health
Department - Kentucky
Lincoln County Health
Department - Kentucky
Pennyrile District Health
Department - Kentucky
Deering Health Department New Hampshire
Effingham Health
Department - New
Hampshire
Ellsworth Health Department
- New Hampshire
Enfield Health Department New Hampshire
Epping Health Department New Hampshire
Epsom Health Department New Hampshire
Errol Health Department New Hampshire
Exeter Health Department New Hampshire
Farmington Health
Department - New
Hampshire
Fitzwilliam Health
Department - New
Hampshire
Francestown Health
Department - New
Hampshire
Franconia Health Department
- New Hampshire
Franklin Health Department New Hampshire
Freedom Health Department
- New Hampshire
Greenfield Health
Department - New
Hampshire
Fremont Health Department New Hampshire
Greenland Health
Department - New
Hampshire
Gilford Health Department New Hampshire
Greenville Health
Department - New
Hampshire
Gilmanton Health
Department - New
Hampshire
Groton Health Department New Hampshire
Gilsum Health Department New Hampshire
Hampstead Health
Department - New
Hampshire
Goffstown Health
Department - New
Hampshire
Hampton Health Department
- New Hampshire
Gorham Health Department New Hampshire
Botetourt County Health
Department - Virginia
Accomack County Health
Department - Virginia
Brattleboro Vermont
Department of Health Vermont
Northampton County Health
Department - Virginia
Burlington Vermont
Department of Health Vermont
St. Albans Vermont
Department of Health Vermont
Hanover County Health
Department - Virginia
Newport News City Health
Department - Virginia
Barre and Morrisville
Vermont Department of
Health - Vermont
Williamsburg City Health
Department - Virginia
Middlebury and Rutland
Vermont Department of
Health - Vermont
Newport and St. Johnsbury
Vermont Department of
Health - Vermont
Springfield and White River
Junction Vermont
Department of Health Vermont
Adams County Health
Department - Washington
Asotin County Health District
- Washington
Benton-Franklin Health
District - Washington
Kitsap County Health District
- Washington
Mason County Department
of Health Services Washington
Chelan-Douglas Health
District - Washington
Clallam County Health and
Human Services - Washington
Northeast Tri-County Health
District - Washington
Columbia County Public
Health Department Washington
Okanogan County Public
Health - Washington
Cowlitz County Health
Department - Washington
Pacific County Health and
Human Services Department
- Washington
95
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Anadarko PHS Indian Hlth Ctr Oklahoma
Muskogee Indian Health Center Oklahoma
Prairie Band Potawatomi Tribe Kansas
Seminole Nation of Oklahoma Oklahoma
Delaware Nation - Oklahoma
Wyandotte Tribe of Oklahoma Oklahoma
Choctaw Nation Indian Health
Clinic - Oklahoma
Northeastern Tribal Health
System - Oklahoma
Quapaw Tribe of Oklahoma Oklahoma
Modoc Tribal Council - Oklahoma
Kickapoo Health Center - Kansas
Redbird Smith Health Center Oklahoma
Carl Albert Indian Hospital Oklahoma
Tishomingo Chickasaw Health
Center - Oklahoma
Sam Hider Jay Community Clinic Oklahoma
Bearskin Health Center Oklahoma
Iowa Tribe of Kansas & Nebraska
- Kansas
Miami Tribe of Oklahoma Oklahoma
Choctaw Nation Indian Health
Clinic - Oklahoma
Apache Tribe of Oklahoma Oklahoma
Ottawa Tribe of Oklahoma Oklahoma
Iowa Tribe of Oklahoma Oklahoma
Choctaw Nation Health Clinic Oklahoma
Cheyenne & Arapaho Tribes Oklahoma
Kickapoo Tribal Health Center Oklahoma
Choctaw Nation Indian Hlth Clinic
- Oklahoma
Okemah Indian Health Center Oklahoma
Muscogee (Creek) Nation Div. of
Hlth. Adm. - Oklahoma
Tonkawa Tribe of Oklahoma Oklahoma
Diabetes Treatment Center Oklahoma
White Eagle Indian Health Center
- Oklahoma
Cherokee Nation Health Clinic Oklahoma
Eastern Shawnee Tribe - Missouri
Pike County Health
Department - Kentucky
Powell County Health
Department - Kentucky
Purchase District Health
Department - Kentucky
Hart County Center Kentucky
Three Rivers District Health
Department - Kentucky
Todd County Health
Department - Kentucky
Logan County Center Kentucky
Wedco District Health
Department - Kentucky
Metcalfe County Center Kentucky
Whitley County Health
Department - Kentucky
Simpson County Center Kentucky
Woodford County Health
Department - Kentucky
Bowling Green - Warren
County Center - Kentucky
Montgomery County Health
Department - Kentucky
Mason County Center Kentucky
Allen County Health
Department - Kentucky
Robertson County Center Kentucky
Bracken County Health
Department - Kentucky
Bell County Center Kentucky
Mercer County Health
Department - Kentucky
Clay County Center Kentucky
Garrard County Health
Department - Kentucky
Harlan County Center Kentucky
Breckinridge County Health
Department - Kentucky
Jackson County Center Kentucky
Barren County Center Kentucky
Butler County Center Kentucky
Rockcastle County Center Kentucky
Edmonson County Center Kentucky
Lawrence County Health
Department - Kentucky
Bath County Center Kentucky
Hampton Falls - New
Hampshire
Goshen Health Department New Hampshire
Hancock Health Department New Hampshire
Grafton Health Department New Hampshire
Hanover Health Department New Hampshire
Grantham Health
Department - New
Hampshire
Harrisville Health
Department - New
Hampshire
Haverhill Health Department
- New Hampshire
Hebron Health Department New Hampshire
Henniker Health Department
- New Hampshire
Hill Health Department - New
Hampshire
Hillsborough Health
Department - New
Hampshire
Hinsdale Health Department New Hampshire
Holderness Health
Department - New
Hampshire
Hollis Health Department New Hampshire
Hooksett Health Department
- New Hampshire
Hopkinton Health
Department - New
Hampshire
Lee Health Department - New
Hampshire
Hudson Health Department New Hampshire
Jackson Health Department New Hampshire
Lempster Health Department
- New Hampshire
Jaffrey Health Department New Hampshire
Lincoln Health Department New Hampshire
Jefferson Health Department
- New Hampshire
Lisbon Health Department New Hampshire
Kensington Health
Department - New
Hampshire
Litchfield Health Department
- New Hampshire
Kingston Health Department
- New Hampshire
San Juan County Health and
Community Services Washington
Garfield County Health
District - Washington
Public Health - Seattle and
King County - Washington
Grant County Health District Washington
Grays Harbor County Public
Health and Social Services Washington
Skagit County Health
Department - Washington
Island County Health
Department - Washington
Snohomish Health District Washington
Jefferson County Public
Health - Washington
Clark County Public Health Washington
Spokane Regional Health
District - Washington
Kittitas County Health
Department - Washington
Tacoma-Pierce County Health
Department - Washington
Lewis County Public Health
Department - Washington
Thurston County Public
Health and Social Services
Department - Washington
Lincoln County Health
Department - Washington
Wahkiakum County Health
Department - Washington
Walla Walla County Health
Department - Washington
Whatcom County Health
Department - Washington
Whitman County Department
of Health - Washington
Yakima County Health District
- Washington
Klickitat County Health
Department - Washington
Lummi Tribal Health Center Washington
Port Gamble S'Klallam Tribal
Health Clinic - Washington
Quinault Nation Tribal Health
Facility - Washington
Skamania County Health
Department - Washington
Adams County Health &
Human Services Department
- Wisconsin
Appleton City Health
Department - Wisconsin
Ashland County Health
Department - Wisconsin
96
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Delaware Tribe of Indians
(Eastern Oklahoma) - Oklahoma
Absentee Shawnee Tribal Clinic Oklahoma
Durant Health Center - Oklahoma
Kickapoo Tribe of Oklahoma Oklahoma
Pawnee Nation of Oklahoma Oklahoma
Watonga IHS Clinic - Oklahoma
Seneca-Cayuga Tribe of
Oklahoma - Oklahoma
Black Hawk Health Center Oklahoma
Comanche Tribe of Oklahoma Oklahoma
Peoria Tribe of Oklahoma Oklahoma
Cibecue PHS Indian Health Ctr Arizona
Caddo Nation of Oklahoma Oklahoma
Bylas Health Center - Arizona
Salina Community Clinic Oklahoma
AZ Assoc. of Community Hlth Ctr Arizona
Fort McDowell - Wassaja
Memorial Health Center - Arizona
Gila River Indian Community Arizona
Yavapai-Prescott Tribe - Arizona
Yomba Shoshone Tribe - Nevada
Tonto Apache Tribe - Arizona
Paiute Indian Tribe of Utah - Utah
Fort Mojave Indian Tribe Arizona
Pyramid Lake Paiute Tribe Nevada
Washoe Tribal Health Center Nevada
Havasupai Tribe - Arizona
Quechan Tribal Council - Arizona
Fallon Health Center - Nevada
Fort McDermitt Tribe - Nevada
Lovelock Paiute Tribe - Nevada
Chemehuevi Tribe - California
Ak-Chin Indian Community Arizona
White Mountain Apache Tribe Arizona
Cocopah Tribe - Arizona
Las Vegas Paiute Tribe - Nevada
Colorado River Indian Community
- Arizona
Phoenix Indian Center - Arizona
Salt River Indian Community Arizona
Duck Valley Shoshone Tribe Nevada
Salt River Indian Community Arizona
Hualapai Tribe - Arizona
Menifee County Center Kentucky
Morgan County Center Kentucky
Rowan County Center Kentucky
Wolfe County Center Kentucky
Daviess County Center Owensboro - Kentucky
Hancock County Center Kentucky
Adair County Center Kentucky
Henderson County Center Kentucky
Casey County Center Kentucky
McLean County Center Kentucky
Clinton County Center Kentucky
Ohio County Center Kentucky
Cumberland County Center Kentucky
Union County Center Kentucky
Green County Center Kentucky
Webster County Center Kentucky
Knott County Center Kentucky
McCreary County Center Kentucky
Lee County Health Center Kentucky
Pulaski County Center Kentucky
Leslie County Center Kentucky
Russell County Center Kentucky
Letcher County Center Kentucky
Taylor County Center Kentucky
Owsley County Center Kentucky
Wayne County Center Kentucky
Perry County Health Center Kentucky
Breckinridge County Home
Health - Kentucky
Grayson County Center Kentucky
Hardin County Center Kentucky
Larue County Center Kentucky
Littleton Health Department New Hampshire
Laconia Health Department New Hampshire
Londonderry Health
Department - New
Hampshire
Lancaster Health Department
- New Hampshire
Loudon Health Department New Hampshire
Landaff Health Department New Hampshire
Lyman Health Department New Hampshire
Langdon Health Department New Hampshire
Lyme Health Department New Hampshire
Lyndeborough Health
Department - New
Hampshire
Madbury Health Department
- New Hampshire
Madison Health Department
- New Hampshire
Marlborough Health
Department - New
Hampshire
Marlow Health Department New Hampshire
Mason Health Department New Hampshire
Meredith Health Department
- New Hampshire
Middleton Health
Department - New
Hampshire
Milan Health Department New Hampshire
Milford Health Department New Hampshire
Milton Health Department New Hampshire
New London Health
Department - New
Hampshire
Monroe Health Department New Hampshire
Mont Vernon Health
Department - New
Hampshire
Newbury Health Department
- New Hampshire
Moultonborough Health
Department - New
Hampshire
Newfields Health Department
- New Hampshire
Nelson Health Department New Hampshire
Barron County Health and
Human Services Department
- Wisconsin
Bayfield County Health
Department - Wisconsin
Brown County Health
Department - Wisconsin
Caledonia/Mt. Pleasant
Health Department Wisconsin
Buffalo County Department
of Health and Human
Services - Wisconsin
Burnett County Department
of Health and Human
Services - Wisconsin
Calumet County Health
Department - Wisconsin
Chippewa County
Department of Public Health Wisconsin
Clark County Health
Department - Wisconsin
Columbia County Health
Department - Wisconsin
Crawford County Public
Health - Wisconsin
Cudahy Health Department Wisconsin
DePere Department of Public
Health - Wisconsin
Dodge County Human
Services and Health
Department - Wisconsin
Door County Public Health
Department - Wisconsin
Douglas County Health and
Human Services - Wisconsin
Dunn County Health
Department - Wisconsin
Eau Claire City-County Health
Department - Wisconsin
Florence County Health
Department - Wisconsin
Fond du Lac County Health
Department - Wisconsin
Forest County Health
Department - Wisconsin
Franklin Health Department Wisconsin
Grant County Health
Department - Wisconsin
Green County Health
Department - Wisconsin
Green Lake County Human
Services - Health Unit Wisconsin
Greendale Health
Department - Wisconsin
Greenfield Health
Department - Wisconsin
Hales Corners Health
Department - Wisconsin
97
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Wells Band Council - Nevada
Ute Indian Tribe - Utah
Yavapai-Apache Nation - Arizona
Battle Mountain Band - Nevada
Ely Shoshone Tribe - Nevada
Reno-Sparks Tribal Health Center
- Nevada
Hopi Health Care Center - Arizona
Tohono O'odham, San Lucy
District - Arizona
Desert Visions Youth Wellness
Center - Arizona
South Fork Band Council - Nevada
Las Vegas Indian Center - Nevada
Moapa Band of Paiutes - Nevada
Walker River Paiute Tribe Nevada
Omak Clinic - Washington
Yerington Paiute Tribe - Nevada
Kaibab-Paiute Tribe - Arizona
Chehalis Tribal Clinic Washington
Moapa Health Clinic - Nevada
Makah Health Center Washington
Goshute Tribe - Utah
Nimiipuu Health - Idaho
Elko Band Council - Nevada
Burns-Paiute Health Clinic Oregon
Te-Moak Tribe of Western
Shoshone - Nevada
Lummi Indian Health Center Washington
Duckwater Shoshone Tribe Nevada
Nooksack Tribal Health Center Washington
Peach Springs Health Center Arizona
Tulalip Clinic - Washington
San Carlos Apache Tribe - Arizona
Kootenai Tribal Health Clinic Idaho
Inchelium Health Clinic Washington
Puyallup Tribal Health Authority Washington
Stillaguamish Tribal Clinic Washington
Port Gamble S'Klallam Tribal
Clinic - Washington
Klamath Tribal Health Center Oregon
Muckleshoot Health & Wellness
Center - Washington
Roger Saux Health Center Washington
Spokane Tribe - Washington
Sauk-Suiattle Health Clinic Washington
Upper Skagit Tribal Clinic Washington
Marion County Center Kentucky
Meade County Health
Department - Kentucky
Nelson County Center Kentucky
Washington County Center Kentucky
Ballard County Center Kentucky
Carter County Center Kentucky
Calloway County Center Kentucky
Elliott County Center Kentucky
Carlisle County Center Kentucky
Henry County Center Kentucky
Shelby County Center Kentucky
Fulton County Center - West
- Kentucky
Spencer County Center Kentucky
Graves County Health
Department - Kentucky
Trimble County Center Kentucky
Hickman County Center Kentucky
Caldwell County Health
Department - Kentucky
Paducah - McCracken County
Center - Kentucky
Crittenden County Health
Department - Kentucky
Carroll County Center Kentucky
Livingston County Health
Department - Kentucky
Gallatin County Center Kentucky
Lyon County Health
Department - Kentucky
Owen County Center Kentucky
Trigg County Health
Department - Kentucky
Pendleton County Center Kentucky
Harrison County Center Kentucky
Nicholas County Center Kentucky
Scott County Center Kentucky
Acadia Parish Health Unit Louisiana
Allen Parish Health Unit Louisiana
Newington Health
Department - New
Hampshire
New Boston Health
Department - New
Hampshire
Newmarket Health
Department - New
Hampshire
New Castle Health
Department - New
Hampshire
Newport Health Department
- New Hampshire
New Durham Health
Department - New
Hampshire
Newton Health Department New Hampshire
New Hampton Health
Department - New
Hampshire
North Hampton Health
Department - New
Hampshire
New Ipswich Health
Department - New
Hampshire
Northfield Health
Department - New
Hampshire
Northumberland Health
Department - New
Hampshire
Northwood Health
Department - New
Hampshire
Nottingham Health
Department - New
Hampshire
Orange Health Department New Hampshire
Orford Health Department New Hampshire
Ossipee Health Department New Hampshire
Pelham Health Department New Hampshire
Pembroke Health
Department - New
Hampshire
Peterborough Health
Department - New
Hampshire
Piermont Health Department
- New Hampshire
Pittsburg Health Department
- New Hampshire
Pittsfield Health Department
- New Hampshire
Plainfield Health Department
- New Hampshire
Iowa County Health
Department - Wisconsin
Iron County Health
Department - Wisconsin
Jackson County Public Health
Department - Wisconsin
Jefferson County Health
Department - Wisconsin
Juneau County Health
Department - Wisconsin
Kenosha County Division of
Health - Wisconsin
Kewaunee County Public
Health Office - Wisconsin
La Crosse County Health
Department - Wisconsin
Lafayette County Health
Department - Wisconsin
Lincoln County Health
Department - Wisconsin
Public Health - Madison and
Dane County - Wisconsin
Manitowoc County Health
Department - Wisconsin
Marathon County Health
Department - Wisconsin
Marinette County Health and
Human Services Department
- Wisconsin
Marquette County Health
Department - Wisconsin
Menasha Health Department
- Wisconsin
Menominee Tribal Clinic Wisconsin
Menominee County Human
Services - Wisconsin
Milwaukee City Health
Department - Wisconsin
Monroe County Health
Agency - Wisconsin
Neenah Department of Public
Health - Wisconsin
Oak Creek Health
Department - Wisconsin
Oconto County Public Health
Division - Wisconsin
Oneida County Health
Department - Wisconsin
City of Oshkosh Health
Services Division - Wisconsin
Outagamie County DHHS,
Public Health Division Wisconsin
Ozaukee County Public
Health Department Wisconsin
Pepin County Health
Department - Wisconsin
Pierce County Public Health
Department - Wisconsin
Polk County Health
Department - Wisconsin
98
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Healing Lodge of Seven Nations Washington
Coquille Tribal Health Center Oregon
Cow Creek Tribal Clinic - Oregon
Niimiipuu Health Center - Idaho
Hoh Tribe - Washington
Swinomish Health Clinic Washington
Siletz Community Health Clinic Oregon
Quileute Clinic - Washington
Shoshone-Bannock Tribe - Idaho
Yellowhawk Tribal Hlth Ctr Oregon
White Swan Clinic - Washington
Quinault Indian Nation Washington
Wadatika Health Center - Oregon
Jamestown S'Klallam Tribe Washington
Indian Tribal Consortium Washington
Kalispel Tribe - Washington
Squaxin Island Health Center Washington
Cowlitz Tribe - Washington
Samish Tribal Health Washington
Skokomish Health Clinic Washington
Grand Ronde Health & Wellness
Center - Oregon
Suquamish Tribe - Washington
Nisqually Health Clinic Washington
Lower Elwha Health Clinic Washington
Santa Rosa Clinic - Arizona
San Xavier PHS Indian Hlth Ctr Arizona
Pascua Yaqui Tribe Health
Services Division - Arizona
Municipality of
Anchorage/Department of Health
and Human Services - Alaska
Tohono O'odham Nation Arizona
Nome Health Center, NortonSound Health Corporation Alaska
Juneau Public Health Center Alaska
North Slope Borough Health and
Social Services Agency - Alaska
Maniilaq Association - Alaska
Aleutian Pribilof Islands
Association - Alaska
Arctic Slope Native Association Alaska
Chickaloon Native Village - Alaska
Kodiak Area Native Association Alaska
Ascension Parish Health Unit
- Louisiana
Assumption Parish Health
Unit - Louisiana
Avoyelles Parish Health Unit
- Louisiana
Region 2 (Capitol Regional
Office) - Louisiana
Beauregard Parish Health
Unit - Louisiana
Region 6 (Central Regional
Office) - Louisiana
Bienville Parish Health Unit Louisiana
Region 9 (Southeast Regional
Office) - Louisiana
Bossier Parish Health Unit Louisiana
Region 1 (Metro Regional
Office) - Louisiana
Caddo Parish Health Unit Louisiana
Region 8 (Northeast Regional
Office) - Louisiana
Calcasieu Parish Health Unit Louisiana
Region 7 (Northwest
Regional Office) - Louisiana
Caldwell Parish Health Unit Louisiana
Region 5 (Southwest
Regional Office) - Louisiana
Cameron Parish Health Unit Louisiana
Desoto Parish Health Unit Louisiana
Catahoula Parish Health Unit
- Louisiana
East Baton Rouge Parish
Health Unit - Louisiana
Claiborne Parish Health Unit
- Louisiana
East Carroll Parish Health
Unit - Louisiana
Concordia Parish Health Unit
- Louisiana
East Feliciana Parish Health
Unit - Louisiana
Region 4 (Acadian Regional
Office) - Louisiana
Evangeline Parish Health
Unit - Louisiana
Franklin Parish Health Unit Louisiana
Grant Parish Health Unit Louisiana
Iberia Parish Health Unit Louisiana
Iberville Parish Health Unit Louisiana
Jackson Parish Health Unit Louisiana
Plymouth Health Department
- New Hampshire
Rye Health Department New Hampshire
Randolph Health Department
- New Hampshire
Raymond Health Department
- New Hampshire
Salisbury Health Department
- New Hampshire
Richmond Health
Department - New
Hampshire
Sanbornton Health
Department - New
Hampshire
Rindge Health Department New Hampshire
Sandown Health Department
- New Hampshire
Rollinsford Health
Department - New
Hampshire
Sandwich Health Department
- New Hampshire
Roxbury Health Department New Hampshire
Seabrook Health Department
- New Hampshire
Rumney Health Department New Hampshire
Sharon Health Department New Hampshire
Shelburne Health
Department - New
Hampshire
South Hampton Health
Department - New
Hampshire
Springfield Health
Department - New
Hampshire
Stark Health Department New Hampshire
Stewartstown Health
Department - New
Hampshire
Stoddard Health Department
- New Hampshire
Strafford Health Department
- New Hampshire
Stratford Health Department
- New Hampshire
Stratham Health Department
- New Hampshire
Sugar Hill Health Department
- New Hampshire
Sullivan Health Department New Hampshire
Sunapee Health Department New Hampshire
Surry Health Department New Hampshire
Portage County Health and
Human Services - Wisconsin
Price County Health
Department - Wisconsin
Racine City Health
Department - Wisconsin
Richland County Health
Department - Wisconsin
Rock County Health
Department - North Office Wisconsin
Rusk County Department of
Health & Human Services Wisconsin
Sauk County Health
Department - Wisconsin
Sawyer County Health and
Human Services - Wisconsin
Shawano County Health
Department - Wisconsin
Sheboygan County Division of
Public Health - Wisconsin
Shorewood/Whitefish Bay
Health Department Wisconsin
South Milwaukee Health
Department - Wisconsin
St. Francis Health
Department - Wisconsin
St. Croix County Dept. of
Human and Health Services Public Health - Wisconsin
Stockbridge-Munsee Health
and Wellness Center Wisconsin
Taylor County Health
Department - Wisconsin
Trempealeau County Public
Health Department Wisconsin
Vernon County Health
Department - Wisconsin
Vilas County Public Health
Department - Wisconsin
Walworth County Health and
Human Services - Wisconsin
Washburn County Health Wisconsin
Washington County Health
Department - Wisconsin
Watertown Department of
Public Health - Wisconsin
Waukesha County Public
Health Division - Wisconsin
Waupaca County Health
Services Division - Wisconsin
Waushara County Health
Department - Wisconsin
Wauwatosa Health
Department - Wisconsin
West Allis Health Department
- Wisconsin
99
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Bethel Center and Itinerant
Nursing Services - Alaska
Native Village of Eklutna - Alaska
Southcentral Foundation - Alaska
Cordova Public Health Center
South Central Region - Alaska
Tanana Chiefs Conference Alaska
Craig Public Health Center Alaska
Yukon-Kuskokwin Health - Alaska
Delta Junction Public Health
Center - Alaska
Alaska Native Tribal Health
Consortium - Alaska
Dillingham Public Health Center Alaska
Fairbanks Regional Public Health
Center Interior Region - Alaska
Fort Yukon Public Health Center Alaska
Galena Public Health Center
Interior Region - Alaska
Haines Public Health Center Alaska
Homer Public Health Center Alaska
Kenai Public Health Center Alaska
Ketchikan Public Health Center Alaska
Kodiak Public Health Center Alaska
Seward Public Health Center Alaska
Matanuska-Susitna (Mat-Su)
Public Health Center - Alaska
Petersburg Public Health Center Alaska
Sitka Public Helath Center Alaska
Tok Public Health Center - Alaska
Valdez Public Health Center Alaska
Wrangell Public Health Center Alaska
South Central Region - Alaska
Southwest Region - Alaska
Interior Region - Alaska
Butler County Health Department
- Alabama
Southeast Region - Alaska
Autauga County Health
Department - Alabama
Calhoun County Health
Department - Alabama
Baldwin County Health
Department - Alabama
Chambers County Health
Department - Alabama
Barbour County Health
Department - Alabama
Jefferson Davis Parish Health
Unit - Louisiana
Red River Parish Health Unit
- Louisiana
Lafayette Parish Health Unit Louisiana
Region 3 (Office of Public
Health) - Louisiana
Richland Parish Health Unit Louisiana
Lasalle Parish Health Unit Louisiana
Sabine Parish Health Unit Louisiana
Lincoln Parish Health Unit Louisiana
St. Bernard Parish Health
Unit - Louisiana
Livingston Parish Health Unit
- Louisiana
St. Charles Parish
Community Health Center Louisiana
Madison Parish Health Unit Louisiana
St. Helena Parish Health Unit
- Louisiana
Natchitoches Parish Health
Unit - Louisiana
St. James Parish Health Unit Louisiana
City of New Orleans
Department of Health Louisiana
St. John Parish Health Unit Louisiana
Ouachita Parish Health Unit Louisiana
St. Landry Parish Health Unit
- Louisiana
Plaquemines Parish Health
Department - Louisiana
St. Martin Parish Health Unit
- Louisiana
Pointe Coupee Parish Health
Unit - Louisiana
St. Mary Parish Health Unit Louisiana
Rapides Parish Health Unit Louisiana
St. Tammany Parish Health
Unit - Louisiana
Tangipahoa Parish Health
Unit - Louisiana
Tensas Parish Health Unit Louisiana
Terrebonne Parish Health
Unit - Louisiana
Union Parish Health Unit Louisiana
Vermilion Parish Health Unit
- Louisiana
Sutton Health Department New Hampshire
Swanzey Health Department
- New Hampshire
Tamworth Health
Department - New
Hampshire
Walpole Health Department New Hampshire
Temple Health Department New Hampshire
Thornton Health Department
- New Hampshire
Warner Health Department New Hampshire
Tilton Health Department New Hampshire
Warren Health Department New Hampshire
Troy Health Department New Hampshire
Washington Health
Department - New
Hampshire
Tuftonboro Health
Department - New
Hampshire
Waterville Valley Health
Department - New
Hampshire
Unity Health Department New Hampshire
Weare Health Department New Hampshire
Wakefield Health
Department - New
Hampshire
Webster Health Department New Hampshire
Wentworth Health
Department - New
Hampshire
Westmoreland Health
Department - New
Hampshire
Whitefield Health
Department - New
Hampshire
Wilmot Health Department New Hampshire
Wilton Health Department New Hampshire
Winchester Health
Department - New
Hampshire
Windham Health Department
- New Hampshire
Wolfeboro Health
Department - New
Hampshire
Windsor Health Department New Hampshire
Winnebago County Health
Department - Wisconsin
Wood County Health
Department - Wisconsin
Langlade County Health
Department - Wisconsin
Western Racine County
Health Department Wisconsin
North Shore Health
Department - Wisconsin
Bad River Tribal Health
Services - Wisconsin
Forest County Potawatomi
Health and Wellness Center Wisconsin
Ho-Chunk Nation Health
Department - Wisconsin
Lac Courte Oreilles
Community Health Center Wisconsin
Oneida Community Health
Center - Wisconsin
Peter Christensen Health
Center - Wisconsin
Red Cliff Community Health
Center - Wisconsin
St. Croix Tribal Health Center
- Wisconsin
Sokaogon Chippewa Health
Clinic - Wisconsin
Barbour County Health
Department - West Virginia
Beckley-Raleigh County
Health Department - West
Virginia
Boone County Health
Department - West Virginia
Braxton County Health
Department - West Virginia
Brooke County Health
Department - West Virginia
Cabell-Huntington Health
Department - West Virginia
Clay County Health
Department - West Virginia
Doddridge County Health
Department - West Virginia
Fayette County Health
Department - West Virginia
Gilmer County Health
Department - West Virginia
Grant County Health
Department - West Virginia
Greenbrier County Health
Department - West Virginia
Hampshire County Health
Department - West Virginia
Hancock County Health
Department - West Virginia
Hardy County Health
Department - West Virginia
100
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Cherokee County Health
Department - Alabama
Bibb County Health Department Alabama
Chilton County Health
Department - Alabama
Blount County Health
Department - Alabama
Bullock County Health
Department - Alabama
Choctaw County Health
Department - Alabama
Clarke County Health Department
- Alabama
Clay County Health Department Alabama
Cleburne County Health
Department - Alabama
Coffee County Health
Department - Alabama
Colbert County Health
Department - Alabama
Conecuh County Health
Department - Alabama
Coosa County Health Department
- Alabama
Cullman County Health
Department - Alabama
Covington Health Department Alabama
Dale County Health Department Alabama
Crenshaw County Health
Department - Alabama
Dallas County Health Department
- Alabama
DeKalb County Health
Department - Alabama
Alabama Public Health Area 3 Alabama
Elmore County Health
Department - Alabama
Escambia County Health
Department - Alabama
Etowah County Health
Department - Alabama
Fayette County Health
Department - Alabama
Franklin County Health
Department - Alabama
Jackson County Health
Department - Alabama
Geneva County Health
Department - Alabama
Greene County Health
Department - Alabama
Jefferson County Department of
Health/Alabama Public Health
Area 4 - Alabama
Hale County Health Department Alabama
Lamar County Health Department
- Alabama
Vernon Parish Health Unit Louisiana
Alford Board of Health Massachusetts
Washington Parish Health
Unit - Louisiana
Amesbury Health
Department - Massachusetts
Webster Parish Health Unit Louisiana
Amherst Health Department
- Massachusetts
West Baton Rouge Parish
Health Unit - Louisiana
West Carroll Parish Health
Unit - Louisiana
Andover Health Department
- Massachusetts
West Feliciana Parish Health
Unit - Louisiana
Arlington Board of Health Massachusetts
Winn Parish Health Unit Louisiana
Athol Board of Health Massachusetts
Jefferson Parish Health Unit Louisiana
Attleboro Health
Department - Massachusetts
Lafourche Parish Health Unit
- Louisiana
Auburn Health Department Massachusetts
Morehouse Parish Health
Unit - Louisiana
Avon Board of Health Massachusetts
Abington Board of Health Massachusetts
Barnstable County
Health/Environmental
Department - Massachusetts
Acton Health Department Massachusetts
Barnstable Town Health
Department - Massachusetts
Agawam Health Department
- Massachusetts
Barre Board of Health/Health
Department - Massachusetts
Becket Board of Health Massachusetts
Bedford Board of Health Massachusetts
Bellingham Board of Health Massachusetts
Belmont Health Department
- Massachusetts
Berkley Health Department Massachusetts
Bernardston Health
Department - Massachusetts
Woodstock Health
Department - New
Hampshire
Bedford Health Department New Hampshire
Boscawen Health
Department - New
Hampshire
Bath City Health Department
- New Hampshire
Mercer County Division of
Public Health - New Jersey
Atlantic County Division of
Public Health - New Jersey
Bayonne Health Department
- New Jersey
Burlington County Health
Department - New Jersey
Morris County Office of
Health Management - New
Jersey
Bergen County Department
of Health Services - New
Jersey
Camden County Department
of Health and Human
Services - New Jersey
Bergenfield Health
Department - New Jersey
Cape May County Health
Department - New Jersey
Bernards Township Health
Department - New Jersey
Clifton Health Department New Jersey
Bloomfield Health
Department - New Jersey
Closter Boro Board of Health
- New Jersey
Branchburg Township Health
Department - New Jersey
Colts Neck Township Health
Department - New Jersey
Bridgewater Township
Division of Health - New
Jersey
Cranford Board of Health New Jersey
South Orange Health
Department - New Jersey
Denville Township Health
Department - New Jersey
Dover Health Department New Jersey
Union County Office of
Health Management - New
Jersey
East Hanover Township
Health Department - New
Jersey
East Orange Health
Department - New Jersey
Harrison-Clarksburg Health
Department - West Virginia
Jackson County Health
Department - West Virginia
Jefferson County Health
Department - West Virginia
Kanawha-Charleston Health
Department - West Virginia
Lewis County Health
Department - West Virginia
Logan County Health
Department - West Virginia
Marion County Health
Department - West Virginia
Marshall County Health
Department - West Virginia
Mason County Health
Department - West Virginia
McDowell County Health
Department - West Virginia
Mercer County Health
Department - West Virginia
Mid-Ohio Valley Health
Department - West Virginia
Mineral County Health
Department - West Virginia
Mingo County Health
Department - West Virginia
Monongalia County Health
Department - West Virginia
Monroe County Health
Department - West Virginia
Morgan County Health
Department - West Virginia
Nicholas County Health
Department - West Virginia
Pendleton County Health
Department - West Virginia
Pocahontas County Health
Department - West Virginia
Preston County Health
Department - West Virginia
Putnam County Health
Department - West Virginia
Berkeley County Health
Department - West Virginia
Randolph-Elkins Health
Department - West Virginia
Summers County Health
Department - West Virginia
Grafton-Taylor County Health
Department - West Virginia
Tucker County Health
Department - West Virginia
Upshur-Buckhannon Health
Department - West Virginia
Wayne County Health
Department - West Virginia
Webster County Health
Department - West Virginia
Wetzel-Tyler County Health
Department - West Virginia
101
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Henry County Health Department
- Alabama
Lauderdale County Health
Department - Alabama
Houston County Health
Department - Alabama
Lawrence County Health
Department - Alabama
Lee County Health Department Alabama
Limestone County Health
Department - Alabama
Lowndes County Health
Department - Alabama
Macon County Health
Department - Alabama
Madison County Health
Department - Alabama
Marengo County Health
Department - Alabama
Marion County Health
Department - Alabama
Montgomery County Health
Department - Alabama
Marshall County Health
Department - Alabama
Mobile County Health
Department/Alabama Public
Health Area 11 - Alabama
Alabama Public Health Area 2 Alabama
Monroe County Health
Department - Alabama
Alabama Public Health Area 5 Alabama
Perry County Health Department
- Alabama
Pickens County Health
Department - Alabama
Pike County Health Department Alabama
Randolph County Health
Department - Alabama
Russell County Health
Department - Alabama
Shelby County Department of
Health - Alabama
St. Clair County Health
Department - Alabama
Sumter County Health
Department - Alabama
Washington County Health
Department - Alabama
Talladega County Health
Department - Alabama
Tallapoosa County Health
Department - Alabama
Wilcox County Health
Department - Alabama
Tuscaloosa County Health
Department - Alabama
Winston County Health
Department - Alabama
Buckland Health Department
- Massachusetts
Billerica Health Department Massachusetts
Boston Public Health
Commission - Massachusetts
Burlington Board of Health Massachusetts
Bourne Health Department Massachusetts
Cambridge Public Health
Department - Massachusetts
Boxford Health Department Massachusetts
Canton Board of Health Massachusetts
Boylston Board of Health Massachusetts
Carlisle Health Department Massachusetts
Braintree Board of Health Massachusetts
Carver Health Department Massachusetts
Brewster Health Department
- Massachusetts
Charlemont Board of Health
- Massachusetts
Bridgewater Board of Health
- Massachusetts
Charlton Board of Health Massachusetts
Brimfield Health Department
- Massachusetts
Chatham Board of Health Massachusetts
Chelmsford Board of Health Massachusetts
Brockton Health Department
- Massachusetts
Chelsea Department of
Health and Human Services Massachusetts
Brookfield Health
Department - Massachusetts
Cheshire Board of Health Massachusetts
Brookline Department of
Public Health Massachusetts
Chester Health Department Massachusetts
Chicopee Health Department
- Massachusetts
Chilmark Board of Health Massachusetts
Everett Board of Health Massachusetts
Newburyport Health
Department - Massachusetts
Dover Board of Health Massachusetts
Borough of Roselle - New
Jersey
Elizabeth Department of
Health and Human Services New Jersey
Edison Department of Health
and Human Resources - New
Jersey
Elmwood Park Department of
Health - New Jersey
City of Englewood
Department of Health - New
Jersey
Ewing Township Health
Department - New Jersey
Fair Lawn Health Department
- New Jersey
Essex County Health
Department - New Jersey
Fort Lee Department of
Health - New Jersey
Freehold Township Health
Department - New Jersey
Gloucester County
Department of Health - New
Jersey
Hopatcong Board of Health New Jersey
Hackensack Department of
Health - New Jersey
Hamilton Township
Department of Health - New
Jersey
Hanover Township Health
Department - New Jersey
Hunterdon County Health
Department - New Jersey
Harrison Health Department New Jersey
Irvington Health Department
- New Jersey
Hillsborough Township Board
of Health - New Jersey
Jefferson Township Health
Department - New Jersey
Hoboken Health Department
- New Jersey
Jersey City Division of Health
- New Jersey
Kearny Health Department New Jersey
Lincoln Park Health
Department - New Jersey
Linden Board of Health - New
Jersey
Livingston Health
Department - New Jersey
Long Beach Island Health
Department - New Jersey
Long Branch Department of
Health - New Jersey
Madison Boro Board of
Health - New Jersey
Wheeling-Ohio County
Health Department - West
Virginia
Wyoming County Health
Department - West Virginia
Lincoln County Health
Department - West Virginia
Big Horn County Public
Health Nursing Service Wyoming
Campbell County Health
Department - Wyoming
Carbon County Public Health
Nursing - Wyoming
City of Casper-Natrona
County Health Department Wyoming
Cheyenne-Laramie County
Health Department Wyoming
Converse County Public
Health - Wyoming
Crook County Public Health
Nursing Service - Wyoming
Fremont County Public
Health Nursing - Wyoming
Goshen County Public Health
Nursing Service - Wyoming
Hot Springs County Public
Health Nursing Service Wyoming
Johnson County Health
Department - Wyoming
Lincoln County Health
Department - Wyoming
Niobrara County Public
Health Nurse Services Wyoming
Park County Public Health
Nursing - Wyoming
Platte County Public Health
Nursing Service - Wyoming
Sheridan County Public
Health - Wyoming
Sublette County Public Health
Nursing Service - Wyoming
Sweetwater County
Community Nursing Services
- Wyoming
Teton County Public Health Wyoming
Uinta County Public Health
Nursing - Wyoming
Washakie County Public
Health Nursing - Wyoming
Weston County Public Health
Nursing - Wyoming
Albany County Public Health
Nursing - Wyoming
Northern Arapaho Tribal
Health Department Wyoming
102
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Alabama Public Health Area 8 Alabama
Walker County Health
Department - Alabama
Alabama Public Health Area 1 Alabama
Alabama Public Health Area 6 Alabama
Alabama Public Health Area 7 Alabama
Alabama Public Health Area 9 Alabama
Alabama Public Health Area 10 Alabama
Morgan County Health
Department - Alabama
Arkansas County Health Unit Stuttgart - Arkansas
Ashley County Health Unit Crossett - Arkansas
Baxter County Health Unit Arkansas
Bradley County Health Unit Arkansas
Benton County Health Unit Bentonville - Arkansas
Boone County Health
Department - Arkansas
Calhoun County Health Unit Arkansas
Carroll County Health Unit Arkansas
Chicot County Health Unit - Lake
Village - Arkansas
Clark County Health Unit Arkansas
Clay County Health Unit - Piggott
- Arkansas
Cleburne County Health Unit Arkansas
Cleveland County Health Unit Arkansas
Columbia County Health Unit Arkansas
Desha County Health Unit McGehee - Arkansas
Conway County Health Unit Arkansas
Craighead County Health Unit Arkansas
Drew County Health Unit Arkansas
Crawford County Health Unit Arkansas
Faulkner County Health Unit Arkansas
Crittenden County Health Unit West Memphis - Arkansas
Fulton County Health Unit Arkansas
Cross County Health Unit Arkansas
Holden Board of Health Massachusetts
Cohasset Board of Health Massachusetts
Dracut Health Department Massachusetts
Colrain Board of Health Massachusetts
Dudley Board of Health Massachusetts
Concord Board of Health Massachusetts
Duxbury Board of Health Massachusetts
Cummington Health
Department - Massachusetts
East Bridgewater Board of
Health - Massachusetts
Dalton Health Department Massachusetts
East Brookfield Health
Department - Massachusetts
Danvers Board of Health Massachusetts
East Longmeadow Health
Department - Massachusetts
Dartmouth Board of Health Massachusetts
Eastern Franklin County
Health District Massachusetts
Dedham Board of Health Massachusetts
Eastham Board of Health Massachusetts
Deerfield Health Department
- Massachusetts
Easthampton Health
Department - Massachusetts
Town of Dennis Massachusetts
Easton Board of Health Massachusetts
Dighton Health Department Massachusetts
Edgartown Board of Health Massachusetts
Douglas Board of Health Massachusetts
Egremont Health
Department - Massachusetts
Essex Board of Health Massachusetts
Fairhaven Board of Health Massachusetts
Fall River Health Department
- Massachusetts
Falmouth Health
Department - Massachusetts
Fitchburg Health
Department - Massachusetts
Florida Health Department Massachusetts
Manalapan Township Board
of Health - New Jersey
Middle-Brook Regional
Health Commission - New
Jersey
Township of Maplewood
Health Department - New
Jersey
Mid-Bergen Regional Health
Commission - New Jersey
Middlesex County Public
Health Department - New
Jersey
Middletown Township Health
Department - New Jersey
Monmouth County Regional
Health Commission #1 - New
Jersey
Montclair Department of
Health and Human Services New Jersey
Montgomery Township
Health Department - New
Jersey
Montville Township Health
Department - New Jersey
Morristown Division of
Health - New Jersey
Mount Olive Township Health
Department - New Jersey
City of Passaic Health
Department - New Jersey
North West Bergen Regional
Health Commission - New
Jersey
City of Newark Department
of Child & Family Well-Being New Jersey
Passaic County Health
Department - New Jersey
Ocean County Board of
Health - New Jersey
Paterson Division of Health New Jersey
Palisades Park Health
Department - New Jersey
Lawrence Township Health
Department - New Jersey
Paramus Board of Health New Jersey
Pequannock Township Board
of Health - New Jersey
Parsippany Health
Department - New Jersey
Princeton Regional Health
Commission - New Jersey
Rahway Health Department New Jersey
Randolph Township Board of
Health - New Jersey
Ringwood Health
Department - New Jersey
Shoshone Tribal Health
Department - Wyoming
Alabama Department of
Public Health - Alabama
Alaska Department of Health
and Social Services - Alaska
Arizona Department of
Health Services - Arizona
Arkansas Department of
Health - Arkansas
California Health and Human
Services - California
Colorado Department of
Public Health and
Environment - Colorado
Connecticut Department of
Public Health - Connecticut
Delaware Division of Public
Health - Delaware
District of Columbia
Department of Health Washington, DC
Florida Department of Health
- Florida
Georgia Department of
Community Health - Georgia
Hawaii State Department of
Health - Hawaii
Idaho Department of Health
and Welfare - Idaho
Illinois Department of Public
Health - Illinois
Indiana Department of
Health - Indiana
Iowa Department of Public
Health - Iowa
Kansas Department of Health
and Environment - Kansas
Kentucky Department of
Public Health - Kentucky
Louisiana Department of
Health and Hospitals Louisiana
Maine Centers for Disease
Control and Prevention Maine
Maryland Department of
Health and Mental Hygiene Maryland
Massachusetts Department
of Public Health Massachusetts
Minnesota Department of
Health - Minnesota
Mississippi State Department
of Health - Mississippi
Missouri Department of
Health and Senior Services Missouri
Montana Department of
Public Health - Montana
103
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Garland County Health Unit Arkansas
Dallas County Health Unit Arkansas
Grant County Health Unit Arkansas
Greene County Health Unit Arkansas
Hempstead County Health Unit Arkansas
Hot Spring County Health Unit Arkansas
Howard County Health Unit Arkansas
Independence County Health Unit
- Arkansas
Izard County Health Unit Arkansas
Jackson County Health Unit Arkansas
Jefferson County Health Unit Arkansas
Lafayette County Health Unit Arkansas
Johnson County Health Unit Arkansas
Lawrence County Health Unit Arkansas
Lee County Health Unit - Arkansas
Lincoln County Health Unit Arkansas
Little River County Health Unit Arkansas
Logan County Health Unit - Paris Arkansas
Lonoke County Health Unit Lonoke - Arkansas
Madison County Health Unit Arkansas
Ouachita County Health Unit Arkansas
Marion County Health Unit Arkansas
Perry County Health Unit Arkansas
Miller County Health Unit Arkansas
Phillips County Health Unit Arkansas
Mississippi County Health Unit Blytheville - Arkansas
Pike County Health Unit Arkansas
Monroe County Health Unit Arkansas
Poinsett County Health Unit Harrisburg - Arkansas
Montgomery County Health Unit
- Arkansas
Polk County Health Unit Arkansas
Nevada County Health Unit Arkansas
Granby Board of Health Massachusetts
Foothills Health District Massachusetts
Foxborough Health
Department - Massachusetts
Granville Health Department
- Massachusetts
Framingham Health
Department - Massachusetts
Great Barrington Health
Department - Massachusetts
Freetown Health
Department - Massachusetts
Greenfield Health
Department - Massachusetts
Gardner Health
Department/Board of Health
- Massachusetts
Groveland Health
Department - Massachusetts
Aquinnah Board of Health Massachusetts
Hadley Board of Health Massachusetts
Georgetown Board of Health
- Massachusetts
Halifax Board of Health Massachusetts
Gill Board of Health Massachusetts
Gloucester Health
Department - Massachusetts
Hamilton Health Department
- Massachusetts
Gosnold Health Department
- Massachusetts
Hampden Health
Department - Massachusetts
Grafton Health Department Massachusetts
Hancock Health Department
- Massachusetts
Hanover Board of Health Massachusetts
Hanson Health
Department/Board of Health
- Massachusetts
Hardwick Board of Health Massachusetts
Harwich Health Department
- Massachusetts
Hatfield Health Department Massachusetts
Haverhill Health and
Inspectional Services Massachusetts
Winchester Board of Health Massachusetts
Hawley Board of Health Massachusetts
Windsor Health Department
- Massachusetts
Rockaway Township Health
Department - New Jersey
Roxbury Township Health
Department - New Jersey
Cumberland/Salem County
Department of Health - New
Jersey
South Brunswick Township
Health Department - New
Jersey
City of Trenton Department
of Health - New Jersey
Sussex County Department of
Environmental and Public
Health - New Jersey
Teaneck Department of
Health and Human Services New Jersey
Township of Union
Department of Health - New
Jersey
Vineland Department of
Health - New Jersey
Warren County Health
Department - New Jersey
Township of Washington
Local Health Agency - New
Jersey
West Caldwell Health
Department - New Jersey
West Milford Health
Department - New Jersey
West Orange Health
Department - New Jersey
Westfield Regional Health
Department - New Jersey
Woodbridge Township
Department of Health and
Human Services - New Jersey
Somerset County Health
Department - New Jersey
Hopewell Township Health
Department - New Jersey
Atlantic City Health
Department - New Jersey
North Bergen Health
Department - New Jersey
Clark Health Department New Jersey
Plainfield Health Department
- New Jersey
West New York Health
Department - New Jersey
Washington Township Health
Department - New Jersey
Monmouth County Health
Department - New Jersey
West Windsor Health
Department - New Jersey
Hudson Regional Health
Commission - New Jersey
Essex Regional Health
Commission - New Jersey
Nebraska Department of
Health and Human Services Nebraska
Nevada Department of
Health and Human Services Nevada
New Hampshire Department
of Health and Human
Services - New Hampshire
New Jersey Department of
Health and Senior Services New Jersey
New Mexico Department of
Health - New Mexico
New York Department of
Health - New York
NC Department of Health and
Human Services - North
Carolina
North Dakota Department of
Health - North Dakota
Ohio Department of Health Ohio
West Virginia Department of
Health and Human Resources
- West Virginia
Oklahoma State Department
of Health - Oklahoma
Oregon Department of
Human Services - Oregon
Wisconsin Department of
Health Services - Wisconsin
Pennsylvania Department of
Health - Pennsylvania
Wyoming Department of
Health - Wyoming
Rhode Island Department of
Health - Rhode Island
California Department of
Veterans Affairs, Veterans
Health Administration California
SC Department of Health and
Environmental Control South Carolina
South Dakota Department of
Health - South Dakota
Tennessee Department of
Health - Tennessee
Texas Department of State
Health Services - Texas
Utah Department of Health Utah
Vermont Department of
Health - Vermont
Virginia Department of
Health - Virginia
Washington State
Department of Health Washington
Other:
Eastern Band of Cherokee
Indians Public Health and
104
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Pope County Health Unit Arkansas
Newton County Health Unit Arkansas
Prairie County Health Unit Arkansas
Pulaski Health Unit - Central Little
Rock - Arkansas
Randolph County Health Unit Arkansas
Saline County Health Unit Arkansas
Scott County Health Unit Arkansas
Searcy County Health Unit Arkansas
Sebastian County Health Unit Arkansas
Sevier County Health Unit Arkansas
Sharp County Health Unit Arkansas
St. Francis County Health Unit Forrest City - Arkansas
Stone County Health Unit Arkansas
Union County Health Unit Arkansas
Van Buren County Health Unit Arkansas
Washington County Health Unit Arkansas
White County Health Unit Searcy - Arkansas
Pulaski County Health Unit Southwest Little Rock - Arkansas
Woodruff County Health Unit Arkansas
Yell County Health Unit Dardanelle - Arkansas
Pulaski County Health Unit North Little Rock - Arkansas
Franklin County Health Unit Arkansas
Pulaski County Health Unit Jacksonville - Arkansas
Central Public Health Region Arkansas
Apache County Health
Department - Arizona
Northeast Region Office Arkansas
Cochise County Health
Department - Arizona
Northwest Region Office Arkansas
Coconino County Public Health
Services District - Arizona
Southeast Region Office Arkansas
Gila River Indian Community
Department of Public Health Arizona
Heath Health Department Massachusetts
Winthrop Health
Department - Massachusetts
Hingham Health Department
- Massachusetts
Holyoke Health Department
- Massachusetts
Woburn Health Department
- Massachusetts
Hinsdale Board of Health Massachusetts
Hopedale Board of Health Massachusetts
Worthington Health
Department - Massachusetts
Hopkinton Health
Department - Massachusetts
Holbrook Board of Health Massachusetts
Hubbardston Health
Department - Massachusetts
Wrentham Board of Health Massachusetts
Hudson Board of Health Massachusetts
Holland Board of Health Massachusetts
Hull Board of Health Massachusetts
Yarmouth Health
Department - Massachusetts
Huntington Health
Department - Massachusetts
Holliston Board of Health Massachusetts
Ipswich Board of Health Massachusetts
Kingston Health Department
- Massachusetts
Lakeville Board of Health Massachusetts
Lanesborough Health
Department - Massachusetts
Lawrence Health
Department - Massachusetts
Leicester Health Department
- Massachusetts
Leominster Health
Department - Massachusetts
Lexington Board of Health Massachusetts
Lincoln Health Department Massachusetts
Longmeadow Board of
Health - Massachusetts
City of Lowell Health
Department - Massachusetts
Ludlow Board of Health Massachusetts
Lynn Health Department Massachusetts
Westwood Board of Health New Jersey
Wayne Health Department New Jersey
City of Orange Township New Jersey
Catron County Public Health
Office - New Mexico
Chaves County - Dexter
Public Health Office - New
Mexico
Chaves County - Roswell
Health Office - New Mexico
Cibola County Public Health
Office - New Mexico
Colfax County Public Health
Office - New Mexico
Curry County Public Health
Office - New Mexico
De Baca County Public Health
Office - New Mexico
Dona Ana County - Anthony
Public Health Office - New
Mexico
Dona Ana County - Chaparral
Public Health Office - New
Mexico
Dona Ana County - Las Cruces
Central Public Health Office New Mexico
Eddy County Public Health
Office - New Mexico
Eddy County - Carlsbad Public
Health Office - New Mexico
Grant County Public Health
Office - New Mexico
Guadalupe County Public
Health Office - New Mexico
Harding County Public Health
Office - New Mexico
Hidalgo County Public Health
Office - New Mexico
Lea County - Hobbs Public
Health Office - New Mexico
Lea County - Lovington Public
Health Office - New Mexico
Lincoln County Health Office New Mexico
Los Alamos County Public
Health Office - New Mexico
Luna County Public Health
Office - New Mexico
Mora County Public Health
Office - New Mexico
Otero County Public Health
Office - New Mexico
Rio Arriba North Public
Health Office - New Mexico
Roosevelt County Public
Health Office - New Mexico
San Juan County Public
Health Office - New Mexico
Human Services DivisionNorth Carolina
California Rural Indian Health
Board-California
California Department of
Public Health-California
Georgia Department of Public
Health-Georgia
Guam Department of Public
Health and Social ServicesGuam
Oregon Health AuthorityOregon
Louisiana Office of Public
Health-Louisiana
Louisiana OPH - Bureau of
Family Health-Louisiana
CNMI Commonwealth
Healthcare CorporationSaipan, Northern Mariana
Islands
University of Tennessee at
Chattanooga-Tennessee
105
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
SouthWest Region Office Arkansas
Graham County Health
Department - Arizona
Greenlee County Health
Department - Arizona
La Paz County Health Department
- Arizona
Maricopa County Department of
Public Health - Arizona
Mohave County Department of
Public Health - Arizona
Navajo County Public Health
Services District - Arizona
Pima County Health Department Arizona
Pinal County Health Department Arizona
Santa Cruz County Health
Department - Arizona
Yavapai County Community
Health Services - Arizona
Yuma County Health Department
- Arizona
Gila County Health Department Arizona
White Mountain Apache Health
Authority - Arizona
Fort McDowell Indian
Community/Wassaja Memorial
Health Center - Arizona
Inter-Tribal Health Care Center Arizona
Calaveras County Public Health
Department - California
Pascua Yaqui Health Department
- Arizona
San Carlos Apache Tribe - Arizona
Colusa County Health
Department - California
Tohono O'Odham Health
Department - Arizona
Contra Costa Health Services California
Alameda County Public Health
Department - California
Del Norte County Public Health California
Alpine County Health and Human
Services - California
Amador County, Health and
Human Services Agency California
El Dorado County Health
Department - California
Berkeley City Public Health
Department - California
Fresno County Department of
Public Health - California
Butte County Department of
Public Health - California
Glenn County Health Department
- California
Lynnfield Board of Health Massachusetts
Malden Board of Health Massachusetts
Manchester-by-the-Sea
Board of Health Massachusetts
Medfield Board of Health Massachusetts
Mansfield Board of Health Massachusetts
Marblehead Health
Department - Massachusetts
Medford Department of
Public Health Massachusetts
Marlborough Health
Department - Massachusetts
Medway Board of Health Massachusetts
Marshfield Health
Department - Massachusetts
Melrose Health Department
- Massachusetts
Mashpee Health Department
- Massachusetts
Mendon Board of Health Massachusetts
Mattapoisett Health
Department - Massachusetts
Merrimac Board of Health Massachusetts
Maynard Board of Health Massachusetts
Methuen Health Department
- Massachusetts
Middleborough Health
Department - Massachusetts
Middlefield Health
Department - Massachusetts
Middleton Board of Health Massachusetts
Milford Board of Health Massachusetts
Millbury Health Department
- Massachusetts
Millis Board of Health Massachusetts
Millville Board of Health Massachusetts
Milton Health Department Massachusetts
Monroe Board of Health Massachusetts
Monson Board of Health Massachusetts
Monterey Board of Health Massachusetts
Montgomery Health
Department - Massachusetts
Mount Washington Health
Department - Massachusetts
San Miguel County Public
Health Office - New Mexico
Sandoval County - Cuba
Public Health Office - New
Mexico
Sandoval Commons Public
Health Office - New Mexico
Santa Fe County Health
Office - New Mexico
Sierra County Public Health
Office - New Mexico
Socorro County Health Office
- New Mexico
Taos County Public Health
Office - New Mexico
Torrance County Public
Health Office - New Mexico
Union County Public Health
Office - New Mexico
Valencia County - Belen
Public Health Office - New
Mexico
Valencia County - Los Lunas
Public Health Office - New
Mexico
Bernalillo County - Southeast
Public Health Office - New
Mexico
Albuquerque City
Environmental Health
Department - New Mexico
Bernalillo County
Environmental Health
Department - New Mexico
McKinley County Public
Health Office - New Mexico
San Juan County - Bloomfield
Public Health Office - New
Mexico
Pueblo of Jemez - New
Mexico
Bernalillo County - Northeast
Heights Public Health Office New Mexico
Bernalillo County - North
Valley Public Health Office New Mexico
Bernalillo County - Southwest
Public Health Office - New
Mexico
Bernalillo County - Stanford
Public Health Office - New
Mexico
Dona Ana County - Dona Ana
Village Public Health Office New Mexico
Dona Ana County - East Mesa
Public Health Office - New
Mexico
Dona Ana County - Hatch
Public Health Office - New
Mexico
106
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Humboldt County Department of
Health and Human Services California
Imperial County Health
Department - California
Inyo County Health Department California
Kern County Health Department California
Kings County Health Department
- California
Lake County Department of
Health Services - California
Lassen County Department of
Health and Social Services California
Long Beach City Department of
Health and Human Services California
Madera County Public Health California
Marin County Health and Human
Services - California
Mariposa County Health
Department - California
Mendocino County Dept of Public
Health - California
Merced County Department of
Public Health - California
Modoc County Public Health
Department - California
Mono County Health Department
- California
Monterey County Health
Department - California
Sacramento Department of
Health and Human Services California
Napa County Health and Human
Services Agency - California
Nevada County Public Health
Department - California
San Benito County Health and
Human Services - California
Orange County Health Care
Agency/Public Health - California
San Bernardino County
Department of Public Health California
City of Pasadena Public Health
Department - California
County of San Diego HHS and
Public Health Services - California
Placer County Health and Human
Services - California
San Francisco Department of
Public Health - California
Plumas County Public Health
Agency - California
San Joaquin County Public Health
Services - California
Riverside County Department of
Health - California
Nahant Board of Health Massachusetts
Nantucket Health
Department - Massachusetts
Nashoba Associated Boards
of Health - Massachusetts
Natick Board of Health Massachusetts
Needham Health
Department - Massachusetts
Newton Health Department Massachusetts
New Ashford Health
Department - Massachusetts
New Bedford Health
Department - Massachusetts
Norfolk Health Department Massachusetts
New Braintree Health
Department - Massachusetts
North Adams Health
Department - Massachusetts
New Marlborough Board of
Health - Massachusetts
North Andover Board of
Health - Massachusetts
Newbury Board of Health Massachusetts
North Attleboro Health
Department - Massachusetts
North Brookfield Health
Department - Massachusetts
North Reading Board of
Health - Massachusetts
Northborough Health
Department - Massachusetts
Northbridge Health
Department - Massachusetts
Northampton Board of
Health - Massachusetts
Norton Health Department Massachusetts
Norwell Health Department Massachusetts
Norwood Board of Health Massachusetts
Orange Board of Health Massachusetts
Oak Bluffs Board of Health Massachusetts
Oakham Board of Health Massachusetts
Orleans Health Department Massachusetts
Otis Health Department Massachusetts
Oxford Board of Health Massachusetts
Palmer Health Department Massachusetts
Paxton Health Department Massachusetts
Dona Ana County - Las Cruces
West Public Health Office New Mexico
Dona Ana County - Sunland
Park Public Health Office New Mexico
McKinley County - Crown
Point Healthcare Facility New Mexico
Otero County - Holloman
Public Health Office - New
Mexico
Otero County - Tularosa
Public Health Office - New
Mexico
Rio Arriba South Public
Health Office - New Mexico
Torrance County - Moriarty
Public Health Office - New
Mexico
New Mexico Department of
Health, Northern Region New Mexico
New Mexico Department of
Health, Southern Region New Mexico
Tri-County Partnership of
Chaves, Curry and Roosevelt
Counties - New Mexico
Southern Nevada Health
District - Nevada
Washoe County District
Health Department - Nevada
Fallon Paiute Shoshone Tribal
Health Station - Nevada
Las Vegas Paiute Tribe Health
and Human Services - Nevada
Carson City Health and
Human Services - Nevada
State of Nevada Department
of Health & Human Services,
State Health Division Nevada
Churchill County Health
Center - Nevada
Douglas County Clinic Nevada
Elko County Clinic - Nevada
Humboldt County Clinic Nevada
Lander County Clinic Nevada
Lincoln County Clinic Nevada
Lyon County Clinic - Nevada
Mineral County Public Health
Nurses Office - Nevada
Nye County Clinic - Nevada
Nye and Esmeralda Counties
Clinic - Nevada
Pershing County Clinic Nevada
107
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
San Luis Obispo County Health
Department - California
San Mateo County Health Service
Department - California
Los Angeles County Public Health
Department - California
Santa Clara County Public Health
Department - California
Santa Cruz County Health
Services Agency - California
Shasta County Public Health California
Sierra County Health Department
- California
Sonoma County Department of
Health Services - California
Siskiyou County Public Health
Department - California
Solano County Health and Social
Services Dept. - Public Health California
Stanislaus County Public Health
Department - California
Sutter County Health Department
- California
Tehama County Health Services
Agency - California
Trinity County Health and Human
Services - California
Tulare County Health and Human
Services - California
Tuolumne County Health
Department - California
Ventura County Health
Department - California
Vernon City Health Department California
Indian Health Council, Inc. California
Yolo County Health Department California
Yuba County Health Department California
Scotts Valley Health and Social
Services - California
Santa Barbara County Public
Health Department - California
Southern Indian Health Council,
Inc. - California
San Diego Department of
Environmental Health - California
Toiyabe Indian Health - California
Cold Springs Rancheria Health
Services - California
United Indian Health Services California
Hoopa Valley Tribe - Kima
Medical Center - California
El Dorado County Environmental
Management - California
Alamosa County Public Health
Department - Colorado
City of Peabody Massachusetts
Pembroke Board of Health Massachusetts
Pepperell Health
Department - Massachusetts
Peru Health Department Massachusetts
Plympton Board of Health Massachusetts
Petersham Health
Department - Massachusetts
Phillipston Board of Health Massachusetts
Princeton Health
Department - Massachusetts
Pittsfield Health Department
- Massachusetts
Provincetown Health
Department - Massachusetts
Plainville Health Department
- Massachusetts
Quabbin Health District Massachusetts
Plymouth Health
Department - Massachusetts
Quincy Health Department Massachusetts
Randolph Health
Department - Massachusetts
Raynham Health Department
- Massachusetts
Reading Health Department Massachusetts
Rehoboth Health
Department - Massachusetts
Revere Health Department Massachusetts
Richmond Health
Department - Massachusetts
Rockland Board of Health Massachusetts
Royalston Board Health
Department - Massachusetts
Rockport Health Department
- Massachusetts
Rowe Board of Health Massachusetts
Russell Health Department Massachusetts
Rowley Health Department Massachusetts
Rutland Board of Health Massachusetts
Salem Board of Health Massachusetts
Salisbury Health Department
- Massachusetts
Sandisfield Health
Department - Massachusetts
Sandwich Health
Department - Massachusetts
White Pine County Clinic Nevada
Lyon County/Dayton Clinic Nevada
Lyon County/Yerington Clinic
- Nevada
Reno Sparks Tribal Health
Center - Nevada
Yerington Paiute Tribal Clinic
- Nevada
Albany County Department
of Health - New York
Allegany County Health
Department - New York
Broome County Health
Department - New York
Cattaraugus County Health
Department - New York
Cayuga County Department
of Health and Human
Services - New York
Chautauqua County Health
Department - New York
Chemung County Health
Department - New York
Chenango County Public
Health - New York
Clinton County Department
of Public Health - New York
Columbia County
Department of Health - New
York
Cortland County Health
Department - New York
Delaware County Public
Health - New York
Dutchess County Department
of Health - New York
Erie County Department of
Health - New York
Essex County Public Health
Department - New York
Franklin County Public Health
Services - New York
Fulton County Public Health
Department - New York
Genesee County Health
Department - New York
Greene County Public Health
Nursing Service - New York
Hamilton County Public
Health Nursing Service - New
York
Herkimer County Public
Health Nursing Service - New
York
Jefferson County Public
Health Service - New York
Lewis County Public Health
Agency - New York
Livingston County
Department of Health - New
York
108
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Community Health Services, Inc. Colorado
Pitkin County Environmental
Health Department - Colorado
City and County of Broomfield
Department of Health and
Human Services - Colorado
Bent County Public Health Agency
- Colorado
Boulder County Public Health Colorado
Chaffee County Public Health
Department - Colorado
Cheyenne County Public Health Colorado
Clear Creek County Public &
Environmental Health - Colorado
Conejos County Public Health and
Nursing Service - Colorado
Costilla County Public Health
Agency - Colorado
Hinsdale County Public Health
Agency - Colorado
Custer County Public Health
Agency - Colorado
Delta County Department of
Health and Human Services Colorado
Denver Department of
Environmental Health - Colorado
Dolores County Public Health
Agency - Colorado
Eagle County Health and Human
Services Department - Colorado
El Paso County Public Health Colorado
Elbert County Public Health
Nursing Service - Colorado
Gunnison County Public Health Colorado
Fremont County Public Health
Agency - Colorado
Fremont County Environmental
Health Department - Colorado
Jackson County Public Health
Agency - Colorado
Garfield County Public Health
Nursing Service - Colorado
Jefferson County Public Health Colorado
Gilpin County Public Health
Agency - Colorado
Kiowa County Public Health
Agency - Colorado
Grand County Public Health Colorado
Kit Carson County Public Health
Nursing Service - Colorado
Larimer County Department of
Health and Environment Colorado
Saugus Health Department Massachusetts
Savoy Health Department Massachusetts
Scituate Health Department Massachusetts
Somerset Board of Health Massachusetts
Seekonk Health Department
- Massachusetts
Sharon Health Department Massachusetts
Somerville Health
Department - Massachusetts
Sheffield Health Department
- Massachusetts
South Hadley Health
Department - Massachusetts
Sherborn Health Department
- Massachusetts
Southborough Health
Department - Massachusetts
Shrewsbury Health
Department - Massachusetts
Southbridge Health
Department - Massachusetts
Southampton Health
Department - Massachusetts
Southwick Board of Health Massachusetts
Spencer Board of Health Massachusetts
Springfield Department of
Health and Human Services Massachusetts
Sterling Board of Health Massachusetts
Stoughton Health
Department and Visiting
Nurses Association Massachusetts
Stow Health Department Massachusetts
Sturbridge Board of Health Massachusetts
Sudbury Health Department
- Massachusetts
Sunderland Board of Health Massachusetts
Sutton Health Department Massachusetts
Swampscott Health
Department - Massachusetts
Swansea Board of Health Massachusetts
Taunton Board of Health Massachusetts
Templeton Health
Department - Massachusetts
Tewksbury Board of Health Massachusetts
Tisbury Board of Health Massachusetts
Madison County Health
Department - New York
Monroe County Department
of Public Health - New York
Montgomery County Public
Health - New York
Nassau County Department
of Health - New York
New York City Department of
Health and Mental Hygiene New York
Niagara County Health
Department - New York
Oneida County Health
Department - New York
Onondaga County Health
Department - New York
Ontario County Public Health
- New York
Orleans County Health
Department - New York
Otsego County Department
of Health - New York
Oswego County Health
Department - New York
Putnam County Health
Department - New York
Rensselaer County Health
Department - New York
Rockland County Department
of Health - New York
Saratoga County Public
Health Nursing Services New York
Schenectady County Public
Health Services - New York
Schoharie County Health
Department - New York
Schuyler County Public
Health - New York
Seneca County Health
Department - New York
St. Lawrence County Health
Department - New York
Steuben County Public Health
and Nursing Services - New
York
Suffolk County Department
of Health Services - New York
Sullivan County Public Health
Services - New York
Tioga County Health
Department - New York
Tompkins County Health
Department - New York
Ulster County Health
Department - New York
Warren County Health
Services - New York
Washington County Public
Health Department - New
York
109
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Las Animas-Huerfano County
Health and Environment Colorado
Lincoln County Public Health
Nursing Service - Colorado
Mesa County Health Department
- Colorado
Mineral County Public Health
Nursing Service - Colorado
Montezuma County Health
Department - Colorado
Montrose County Health &
Human Services - Colorado
Ouray County Public Health
Nursing Service - Colorado
Northeast Colorado Health
Department - Colorado
Northwest Colorado Visiting
Nurse Association and Hospice Colorado
Park County Environmental
Health Department - Colorado
Otero County Department of
Health - Colorado
Prowers County Public Health Colorado
Pueblo City-County Health
Department - Colorado
Rio Grande County Public Health
Nursing Service - Colorado
Routt County Environmental
Health Department - Colorado
Saguache County Public Health
Nursing Service - Colorado
San Juan Basin Health
Department - Colorado
San Juan County Public Health
Nursing Service - Colorado
San Miguel County Public Health
Nursing Service - Colorado
Weld County Health Department
of Public Health and Environment
- Colorado
Summit County Public Health
Nursing Service - Colorado
Summit County Environmental
Health Department - Colorado
Rio Blanco County Public Health
Nursing Service - Colorado
Teller County Public Health Colorado
Clear Creek County
Environmental Health
Department - Colorado
Teller County Environmental
Health Department - Colorado
Eagle County Environmental
Health Department - Colorado
Tri-County Health Department Colorado
Kit Carson County Environmental
Health Department - Colorado
Tolland Health Department Massachusetts
Topsfield Board of Health Massachusetts
Tri-Town Health District Massachusetts
Truro Health Department Massachusetts
Tyngsborough Board of
Health - Massachusetts
Tyringham Board of Health Massachusetts
Upton Health Department Massachusetts
Uxbridge Health Department
- Massachusetts
Wakefield Health
Department - Massachusetts
Walpole Health Department
- Massachusetts
Waltham Department of
Health - Massachusetts
Wareham Health
Department - Massachusetts
Warren Health Department Massachusetts
Warwick Board of Health Massachusetts
Washington Health
Department - Massachusetts
Watertown Health
Department - Massachusetts
Wayland Health Department
- Massachusetts
Webster Health Department
- Massachusetts
Weston Health Department Massachusetts
Wellfleet Health Department
- Massachusetts
Wendell Health Department
- Massachusetts
West Boylston Board of
Health - Massachusetts
West Bridgewater Health
Department - Massachusetts
West Brookfield Health
Department - Massachusetts
West Newbury Board of
Health - Massachusetts
West Springfield Health
Department - Massachusetts
West Stockbridge Board of
Health - Massachusetts
West Tisbury Board of Health
- Massachusetts
Westborough Health
Department - Massachusetts
Westfield Health
Department - Massachusetts
Westford Board of Health Massachusetts
Wayne County Public Health
Service - New York
Westchester County Health
Department - New York
Wyoming County Health
Department - New York
Yates County Public Health
Department - New York
Orange County Department
of Health - New York
Seneca Nation of Indians
(New York) Health
Department - New York
Adams County Health District
- Ohio
Akron City Health
Department - Ohio
Allen County Health
Department - Ohio
Alliance City Health
Department - Ohio
Ashland County/City Health
Department - Ohio
Ashtabula County Health
District - Ohio
Ashtabula City Health District
- Ohio
Athens County Health
Department - Ohio
Auglaize County Health
District - Ohio
Barberton City Health District
- Ohio
Belmont County Health
Department - Ohio
Belpre City Health
Department - Ohio
Brown County Health
Department - Ohio
Butler County Health
Department - Ohio
Canton City Health District Ohio
Carroll County Health District
- Ohio
Champaign County Health
District - Ohio
Cincinnati Health Department
- Ohio
Shaker Heights City Health
District - Ohio
Clark County Combined
Health District - Ohio
Clermont County Health
District - Ohio
Cleveland City Department of
Public Health - Ohio
Clinton County Health District
- Ohio
Columbiana County Health
District - Ohio
Columbus Public Health Ohio
110
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Park County Public Health
Nursing Service - Colorado
Southeastern Land and
Environment - Colorado
San Miguel County Environmental
Health Department - Colorado
Town of Vail Environmental
Health - Colorado
Baca County Public Health
Nursing Service - Colorado
Aspen City Environmental Health
Department - Colorado
Bethel Health Department Connecticut
Crowley County Public Health
Nursing Service - Colorado
Denver Health and Hospital
Authority - Colorado
West Hartford-Bloomfield Health
District - Connecticut
Lake County Public Health
Nursing Service - Colorado
Bridgeport Health Department Connecticut
Chatham Health District Connecticut
Bristol-Burlington Health District Connecticut
Brookfield Town Health
Department - Connecticut
Chesprocott Health District Connecticut
Colchester Health Department Connecticut
Lebanon Health Department Connecticut
Cromwell Health Department Connecticut
Danbury Health Department Connecticut
Darien Health Department Connecticut
Essex Health Department Connecticut
Durham Health Department Connecticut
East Hartford Health Department
- Connecticut
Fairfield Health Department Connecticut
East Shore District Health
Department - Connecticut
Farmington Valley Health District
- Connecticut
Easton Health Department Connecticut
Franklin Health Department Connecticut
Glastonbury Health Department Connecticut
Greenwich Department of Health
- Connecticut
Westhampton Health
Department - Massachusetts
Westminster Board of Health
- Massachusetts
Westport Health
Department - Massachusetts
Westwood Board of
Health/Health Department Massachusetts
Weymouth Health
Department - Massachusetts
Whitman Health Department
- Massachusetts
Wilbraham Board of Health Massachusetts
Williamstown Board of
Health - Massachusetts
Wilmington Board of Health Massachusetts
Winchendon Health
Department - Massachusetts
Worcester Department of
Health - Massachusetts
Leyden Board of Health Massachusetts
Montague Health
Department - Massachusetts
Wellesley Health
Department - Massachusetts
Adams Board of Health Massachusetts
Blandford Board of Health Massachusetts
Clinton Board of Health Massachusetts
Conway Board of Health Massachusetts
Franklin Board of Health Massachusetts
New Salem Health
Department - Massachusetts
Plainfield Board of Health Massachusetts
Shelburne Board of Health Massachusetts
Franklin Regional Council of
Governments Massachusetts
Acushnet Health Department
- Massachusetts
City of Beverly Health
Department - Massachusetts
County of Dukes County Massachusetts
Ashland Board of Health Massachusetts
Blackstone Board of Health Massachusetts
Lancaster Board of Health Massachusetts
Chesterfield Board of Health
- Massachusetts
Conneaut City Health District
- Ohio
Coshocton City Health
Department - Ohio
Crawford County General
Health District - Ohio
Cuyahoga County Board of
Health - Ohio
Darke County Health District Ohio
Defiance County General
Health District - Ohio
Delaware General Health
District - Ohio
East Liverpool City Health
District - Ohio
East Palestine City Health
District - Ohio
Elyria City Health District Ohio
Erie County Health District Ohio
Fairfield County Health
District - Ohio
Fayette County Health
Department - Ohio
City of Findlay Health District
- Ohio
Franklin County Health
District - Ohio
Fulton County Health
Department - Ohio
City of Galion Health District Ohio
Gallia County Health District Ohio
Geauga County Health
District - Ohio
City of Girard Health District Ohio
Greene County Combined
Health District - Ohio
Cambridge-Guernsey County
Health District - Ohio
City of Hamilton Health
Department - Ohio
Hamilton County General
Health District - Ohio
Hancock County Health
Department - Ohio
Harrison County Health
Department - Ohio
Henry County Health
Department - Ohio
Highland County Health
District - Ohio
Holmes County Health
District - Ohio
Huron County General Health
District - Ohio
City of Ironton Health District
- Ohio
111
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Griswold Health Department Connecticut
Guilford Health Department Connecticut
Haddam Health Department Connecticut
Hartford Health Department Connecticut
Meriden Department of Health
and Human Services Connecticut
Killingworth Health Department Connecticut
Ledge Light Health District Connecticut
Middlebury Department of
Health - Connecticut
Madison Health Department Connecticut
Middlefield Health Department Connecticut
Manchester Health Department Connecticut
Eastern Highlands Health District
- Connecticut
Middletown Health Department Connecticut
Milford Health Department Connecticut
Trumbull-Monroe Health District
- Connecticut
Naugatuck Valley Health District Connecticut
New Britain Health Department Connecticut
New Canaan Health Department Connecticut
New Fairfield Health Department
- Connecticut
New Haven Health Department Connecticut
Norwalk Health Department Connecticut
New Milford Department of
Health - Connecticut
Newtown Health District Connecticut
Old Lyme Health Department Connecticut
North Central Health District Connecticut
Connecticut River Area Health
District - Connecticut
Northeast District Department of
Health - Connecticut
Orange Health Department Connecticut
Pomperaug Health District Connecticut
Preston Health Department Connecticut
Quinnipiack Valley Health District
- Connecticut
Marion Township Health
Department - Massachusetts
Townsend Board of Health Massachusetts
Wenham Health Department
- Massachusetts
Dunstable Board of Health Massachusetts
Groton Township Board of
Health - Massachusetts
Harvard Township Board of
Health - Massachusetts
Littleton Township Board of
Health - Massachusetts
Rochester Township Board
of Health - Massachusetts
Shirley Township Board of
Health - Massachusetts
Ashburn Board of Health Massachusetts
Ashby Board of Health Massachusetts
Ayer Board of Health Massachusetts
Berlin Board of Health Massachusetts
Bolton Board of Health Massachusetts
Boxborough Board of Health
- Massachusetts
Erving Board of Health Massachusetts
Lenox Board of Health Massachusetts
Leverett Town Board of
Health - Massachusetts
Lunenburg Board of Health Massachusetts
Northfield Board of Health Massachusetts
Pelham Board of Health Massachusetts
Shutesbury Board of Health Massachusetts
Stockbridge Board of Health
- Massachusetts
Ware Board of Health Massachusetts
Allegany County Health
Department - Maryland
Anne Arundel County
Department of Health Maryland
Baltimore City Health
Department - Maryland
Baltimore County
Department of Health Maryland
Calvert County Health
Department - Maryland
Caroline County Health
Department - Maryland
Jackson County Health
Department - Ohio
Jefferson County General
Health District - Ohio
Kent City Health District Ohio
Lorain City Health District Ohio
Kenton-Hardin County Health
District - Ohio
Knox County Health
Department - Ohio
Lorain County Health District
- Ohio
Lake County Health District Ohio
Toledo-Lucas County Health
Department - Ohio
Lawrence County Health
District - Ohio
Madison County-London City
Health District - Ohio
Licking County Health District
- Ohio
District Board of Health
Mahoning County - Ohio
Logan County Health District Ohio
Mansfield/Ontario/Richland
County Health Department Ohio
Logan-Hocking County Health
Department - Ohio
City of Marietta Health
District - Ohio
Massillon City Health District
- Ohio
Medina County Health
District - Ohio
Meigs County Health
Department - Ohio
Mercer County-Celina City
Health Department - Ohio
Miami County Health District
- Ohio
Middletown City Health
District - Ohio
Monroe County Health
Department - Ohio
Morgan County Health
District - Ohio
Public Health-Dayton and
Montgomery County - Ohio
Morrow County Health
Department - Ohio
New Philadelphia City Health
- Ohio
Niles City Health District Ohio
Noble County Health
Department - Ohio
Oakwood City Health District
- Ohio
112
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Redding Health Department Connecticut
Ridgefield Health Department Connecticut
Salem Health Department Connecticut
Sharon Health Department Connecticut
Stonington Health Department Connecticut
Sherman Health Department Connecticut
Somers Health Department Connecticut
Stratford Health Department Connecticut
South Windsor Health
Department - Connecticut
Torrington Area Health District Connecticut
Uncas Health District Connecticut
Stamford City Health Department
- Connecticut
Wallingford Health Department Connecticut
Washington Health Department Connecticut
Waterbury Department of Public
Health - Connecticut
West Haven Health Department Connecticut
Westbrook Health Department Connecticut
Westport-Weston Health District
- Connecticut
Central Connecticut Health
District - Connecticut
Wilton Health Department Connecticut
Chester Health Department Connecticut
Windsor Health Department Connecticut
Mohegan Tribal Health
Department - Connecticut
Lisbon Health Department Connecticut
North Stonington Health Office Connecticut
Lyme Health Department Connecticut
Voluntown Health Department Connecticut
Mashantucket Pequot Health
Department - Connecticut
Plainville-Southington Regional
Health District - Connecticut
Government of the District of
Columbia Department of Health Washington, DC
Carroll County Health
Department - Maryland
Cecil County Health
Department - Maryland
Charles County Health
Department - Maryland
Dorchester County Health
Department - Maryland
Frederick County Health
Department - Maryland
Garrett County Health
Department - Maryland
Harford County Health
Department - Maryland
Howard County Health
Department - Maryland
Kent County Health
Department - Maryland
Montgomery County
Department of Health and
Human Services - Maryland
Prince George's County
Health Department Maryland
Queen Anne's County Health
Department - Maryland
Somerset County Health
Department - Maryland
St. Mary's County Health
Department - Maryland
Talbot County Health
Department - Maryland
Washington County Health
Department - Maryland
Wicomico County Health
Department - Maryland
Worcester County Health
Department - Maryland
Maine DHS/Augusta - Maine
Bangor City Health
Department - Maine
Maine DHS/Bangor - Maine
Downeast District
PublicHealth - Maine
City of Portland Public Health
Division - Maine
Maine DHS/Rockland Maine
Maine DHS/Biddeford Maine
Maine DHS/Calais - Maine
Maine DHS/Ellsworth Maine
Maine DHS/Farmington Maine
Maine DHS/Fort Kent Maine
Maine DHS/Portland - Maine
Maine DHS/Sanford - Maine
Maine DHS/Skowhegan Maine
Maine DHS/Caribou - Maine
Ottawa County Health
Department - Ohio
Paulding County Health
District - Ohio
Perry County Health
Department - Ohio
Putnam County Health
Department - Ohio
Pickaway County Health
District - Ohio
Pike County Health District Ohio
Ravenna City Health District Ohio
Piqua City Health District Ohio
Ross County Health District Ohio
Portage County Health
District - Ohio
Scioto County Health District
- Ohio
Portsmouth City Health
District - Ohio
Seneca County Health District
- Ohio
Preble County Health District
- Ohio
Sharonville City Health
District - Ohio
Sidney-Shelby County Health
Department - Ohio
Springdale City Health District
- Ohio
St. Bernard City Health
District - Ohio
Stark County Combined
General Health District - Ohio
Steubenville City Health
Department - Ohio
Summit County Health
District - Ohio
Van Wert County Health
District - Ohio
Trumbull County Health
Department - Ohio
Tuscarawas County Health
District - Ohio
Vinton County Health District
- Ohio
Union County Health District
- Ohio
Warren County Combined
Health District - Ohio
Warren City Health District Ohio
Washington County Health
Department - Ohio
Wayne County Health District
- Ohio
Williams County Health
District - Ohio
113
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Delaware Department of Health,
Northern Health Services Delaware
Delaware Department of Health,
Southern Health Services Delaware
Duval County Health Department
- Florida
Broward County Health
Department - Florida
Alachua County Health
Department - Florida
Baker County Public Health
Department - Florida
Calhoun County Public Health
Department - Florida
Bay County Health Department Florida
Charlotte County Health
Department - Florida
Bradford County Health
Department - Florida
Citrus County Health Department
- Florida
Brevard County Health
Department - Florida
Clay County Health Department Florida
Collier County Health Department
- Florida
Columbia County Public Health
Department - Florida
Miami-Dade County Health
Department - Florida
DeSoto County Health
Department - Florida
Dixie County Health Department Florida
Escambia County Health
Department - Florida
Flagler County Health
Department - Florida
Hamilton County Health
Department - Florida
Gadsden County Health
Department - Florida
Gilchrist County Health
Department - Florida
Hardee County Health
Department - Florida
Gulf County Health Department Florida
Hendry County Health
Department - Florida
Hernando County Health
Department - Florida
Highlands County Health
Department - Florida
Holmes County Health
Department - Florida
Indian River County Health
Department - Florida
Maine DHS/South Paris Maine
Aroostook Band of MICMAC
- Maine
Houlton Band of Maliseet
Indians of Maine - Maine
Passamaquoddy Indian
Township of Maine Health
Center - Maine
Passamaquoddy Pleasant
Point - Maine
Penobscot Indian Health Maine
Maine DHS/Dover Foxcroft Maine
Maine DHS/Lewiston - Maine
Town of Lubec - Maine
Penquis District Public
Health Unit - Maine
Allegan County Health
Department - Michigan
Barry-Eaton District Health
Department - Michigan
Bay County Health
Department - Michigan
Benzie-Leelanau District
Health Department Michigan
Berrien County Health
Department - Michigan
Branch-Hillsdale-St. Joseph
Community Health Agency Michigan
Calhoun County Health
Department - Michigan
Huron County Health
Department - Michigan
Central Michigan District
Health Department Michigan
Chippewa County Health
Department - Michigan
Public Health DeltaMenominee Counties Michigan
Detroit Health Department Michigan
Dickinson-Iron District
Health Department Michigan
Health Department of
Northwest Michigan Michigan
District Health Department 4
- Michigan
District Health Department
10 - Michigan
District Health Department
#2 - Michigan
Genesee County Health
Department - Michigan
Wood County Health District
- Ohio
Wyandot County Health
District - Ohio
Youngstown City Health
District - Ohio
Adair County Health
Department - Oklahoma
Zanesville-Muskingum
County Health Department Ohio
Struthers City Health
Department - Ohio
Atoka County Health
Department - Oklahoma
Coshocton County Health
Department - Ohio
Beaver County Health
Department - Oklahoma
Marion Public Health
Department - Ohio
Beckham County Health
Department - Oklahoma
City of Salem Health
Department - Ohio
Blaine County Health
Department - Oklahoma
Bryan County Health
Department - Oklahoma
Canadian County Health
Department - Oklahoma
Carter County Health
Department - Oklahoma
Cherokee County Health
Department - Oklahoma
Choctaw County Health
Department - Oklahoma
Cleveland County Health
Department - Oklahoma
Coal County Health
Department - Oklahoma
Creek County Health
Department - Oklahoma
Comanche County Health
Department - Oklahoma
Cotton County Health
Department - Oklahoma
Custer County Health
Department - Oklahoma
Craig County Health
Department - Oklahoma
Delaware County Health
Department - Oklahoma
Garfield County Health
Department - Oklahoma
Garvin County Health
Department - Oklahoma
Grady County Health
Department - Oklahoma
Grant County Health
Department - Oklahoma
Greer County Health
Department - Oklahoma
114
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Jackson County Health
Department - Florida
Jefferson County Health
Department - Florida
Lafayette County Health
Department - Florida
Lake County Health Department Florida
Madison County Health
Department - Florida
Lee County Health Department Florida
Leon County Health Department Florida
Manatee County Health
Department - Florida
Levy County Health Department Florida
Marion County Health
Department - Florida
Martin County Health
Department - Florida
Liberty County Health
Department - Florida
Monroe County Health
Department - Florida
Nassau County Health
Department - Florida
Okaloosa County Health
Department - Florida
Okeechobee County Health
Department - Florida
Orange County Health
Department - Florida
Osceola County Health
Department - Florida
Pasco County Health Department
- Florida
Pinellas County Health
Department - Florida
Polk County Health Department Florida
Sarasota County Health
Department - Florida
Putnam County Health
Department - Florida
Santa Rosa County Health
Department - Florida
Seminole County Health
Department - Florida
St. Johns County Public Health
Department - Florida
St. Lucie County Health
Department - Florida
Sumter County Health
Department - Florida
Suwannee County Health
Department - Florida
Taylor County Health Department
- Florida
Union County Health Department
- Florida
Grand Traverse County
Health Department Michigan
Ingham County Health
Department - Michigan
Ionia County Health
Department - Michigan
Jackson County Health
Department - Michigan
Kalamazoo County Health
and Community Services Michigan
Kent County Health
Department - Michigan
LMAS District Health
Department - Michigan
Lapeer County Health
Department - Michigan
Lenawee County Health
Department - Michigan
Livingston County
Department of Public Health
- Michigan
Macomb County Health
Department - Michigan
Marquette County Health
Department - Michigan
Mid-Michigan District Health
Department - Michigan
Midland County Department
of Public Health - Michigan
Monroe County Health
Department - Michigan
Public Health Muskegon
County - Michigan
Oakland County Health
Division - Michigan
Ottawa County Health
Department - Michigan
Saginaw County Department
of Public Health - Michigan
Sanilac County Health
Department - Michigan
Shiawassee County Health
Department - Michigan
St. Clair County Health
Department - Michigan
Tuscola County Health
Department - Michigan
Van Buren/Cass District
Health Department Michigan
Washtenaw County Public
Health Department Michigan
Wayne County Health
Department - Michigan
Western U.P. District Health
Department - Michigan
Dearborn Health
Department - Michigan
Bay Mills Indian Community Michigan
Harmon County Health
Department - Oklahoma
Haskell County Health
Department - Oklahoma
Kingfisher County Health
Department - Oklahoma
Hughes County Health
Department - Oklahoma
Kiowa County Health
Department - Oklahoma
Jackson County Health
Department - Oklahoma
Latimer County Health
Department - Oklahoma
Jefferson County Health
Department - Oklahoma
LeFlore County Health
Department - Oklahoma
Johnston County Health
Department - Oklahoma
Lincoln County Health
Department - Oklahoma
Kay County Health
Department - Oklahoma
Logan County Health
Department - Oklahoma
Love County Health
Department - Oklahoma
Major County Health
Department - Oklahoma
Marshall County Health
Department - Oklahoma
Mayes County Health
Department - Oklahoma
McClain County Health
Department - Oklahoma
McCurtain County Health
Department - Oklahoma
McIntosh County Health
Department - Oklahoma
Murray County Health
Department - Oklahoma
Noble County Health
Department - Oklahoma
Muskogee County Health
Department - Oklahoma
Harper County Health
Department - Oklahoma
Okfuskee County Health
Department - Oklahoma
Oklahoma City-County Health
Department - Oklahoma
Okmulgee County Health
Department - Oklahoma
Ottawa County Health
Department - Oklahoma
Pawnee County Health
Department - Oklahoma
Payne County Health
Department - Oklahoma
Pittsburg County Health
Department - Oklahoma
115
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Volusia County Department of
Health - Florida
Wakulla County Health
Department - Florida
Bacon County Health Department
- Georgia
Walton County Health
Department - Florida
Washington County Health
Department - Florida
Baker County Health Department
- Georgia
Glades County Health
Department - Florida
Baldwin County Health
Department - Georgia
Appling County Health
Department - Georgia
Banks County Health Department
- Georgia
Atkinson County Health
Department - Georgia
Barrow County Health
Department - Georgia
Bartow County Health
Department - Georgia
Ben Hill County Health
Department - Georgia
Berrien County Health
Department - Georgia
Bibb County Health Department Georgia
Bleckley County Health
Department - Georgia
Brantley County Health
Department - Georgia
Brooks County Health
Department - Georgia
Bryan County Health Department
- Georgia
Bulloch County Health
Department - Georgia
Butts County Health Department
- Georgia
Burke County Health Department
- Georgia
Calhoun County Health
Department - Georgia
Camden County Health
Department - Georgia
Candler County Health
Department - Georgia
Carroll County Health
Department - Georgia
Catoosa County Health
Department - Georgia
Charlton County Health
Department - Georgia
Chatham County Health
Department - Georgia
Coffee County Health
Department - Georgia
Keweenaw Bay Indian
Community/Environmental
Services - Michigan
Sault Ste. Marie Health and
Human Services - Michigan
Aitkin-Itasca-Koochiching
Community Health Board Minnesota
Wilkin County Public Health Minnesota
City of Bloomington Division
of Public Health - Minnesota
Blue Earth County Public
Health Nursing Service Minnesota
Brown County Public Health Minnesota
Carver County Public Health Minnesota
Carlton County Public Health
- Minnesota
Chisago County Health and
Human Service Departments
- Minnesota
Clay County Public Health
Department - Minnesota
St. Louis County Health
Department - Minnesota
Cottonwood-Jackson CHS Minnesota
Countryside Public Health Minnesota
Crow Wing County Health
Services - Minnesota
Dakota County Public Health
Department - Minnesota
Steele Community Health
Services/Public Health
Nursing - Minnesota
Douglas County Public
Health - Minnesota
Edina Health Department Minnesota
Human Services of Faribault
and Martin County Minnesota
Fillmore County Public
Health - Minnesota
Freeborn County Public
Health - Minnesota
Goodhue County Public
Health Services - Minnesota
Stevens-Traverse-Grant
Public Health - Minnesota
Hennepin County Human
Services and Public Health Minnesota
Cook County Public Health Minnesota
Isanti County Public Health
Services - Minnesota
Kandiyohi County Public
Health - Minnesota
Pontotoc County Health
Department - Oklahoma
Stephens County Health
Department - Oklahoma
Pottawatomie County Health
Department - Oklahoma
Texas County Health
Department - Oklahoma
Pushmataha County Health
Department - Oklahoma
Tillman County Health
Department - Oklahoma
Rogers County Health
Department - Oklahoma
Tulsa City-County Health
Department - Oklahoma
Seminole County Health
Department - Oklahoma
Wagoner County Health
Department - Oklahoma
Sequoyah County Health
Department - Oklahoma
Washington County Health
Department - Oklahoma
Woods County Health
Department - Oklahoma
Woodward County Health
Department - Oklahoma
Broken Bow-Choctaw Nation
Health Center - Oklahoma
Choctaw Nation Health Care
Center - Oklahoma
Hugo-Choctaw Nation Indian
Health Clinic - Oklahoma
McAlester-Choctaw Nation
Indian Health Clinic Oklahoma
Benton County Health
Department - Oregon
Osage County Health
Department - Oklahoma
Cimarron County Health
Department - Oklahoma
Clackamas County
Community Health Division Oregon
Baker County Health
Department - Oregon
Clatsop County Health and
Human Services Department
- Oregon
Columbia Health District Oregon
Coos County Health
Department - Oregon
Crook County Health
Department - Oregon
Curry County Health
Department - Oregon
Deschutes County Health
Department - Oregon
Douglas County Health and
Social Services - Oregon
116
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Chattahoochee County Health
Department - Georgia
Chattooga County Health
Department - Georgia
Cherokee County Health
Department - Georgia
Colquitt County Health
Department - Georgia
Clarke County Health Department
- Georgia
Columbia County Health
Department - Georgia
Clay County Health Department Georgia
Cook County Health Department Georgia
Clinch County Health Department
- Georgia
Coweta County Health
Department - Georgia
Cobb County Board of Health Georgia
Crawford County Health
Department - Georgia
Crisp County Health Department Georgia
Dade County Health Department
- Georgia
Dawson County Health
Department - Georgia
District 3, Unit 5: DeKalb Health
District - Georgia
Decatur County Health
Department - Georgia
Floyd County Health Department
- Georgia
District 1, Unit 1: Northwest
District - Georgia
Dooly County Health Department
- Georgia
Gwinnett County Health
Department - Georgia
Dodge County Health
Department - Georgia
Dougherty County Health
Department - Georgia
Douglas County Board of Health Georgia
Early County Health Department Georgia
Echols County Health Department
- Georgia
Effingham County Health
Department - Georgia
Elbert County Health Department
- Georgia
Emanuel County Health
Department - Georgia
Evans County Health Department
- Georgia
Glascock County Health
Department - Georgia
Lincoln-Lyon-MurrayPipestone Public Services Minnesota
Meeker-McLeod-Sibley
Community Health Services
Board - Minnesota
Mille Lacs County Public
Health - Minnesota
Minneapolis Department,
Health and Family Support Minnesota
Becker County Human
Services - Minnesota
Mower County Public Health
Nursing Service - Minnesota
Dodge County Public Health Minnesota
Nobles-Rock Community
Health Service - Minnesota
Olmsted County Public
Health Services - Minnesota
Otter Tail County Public
Health - Minnesota
Houston County Public
Health - Minnesota
Polk County Public Health Minnesota
Washington County
Department of Public Health
and Environment Minnesota
Pope County Health
Department - Minnesota
Quin County Board of Health
- Minnesota
Watonwan County
Community Health Services Minnesota
St. Paul-Ramsey County
Public Health Department Minnesota
Winona Community Health
Services Agency - Minnesota
Redwood-Renville Public
Health Services - Minnesota
Wright County Human
Services - Minnesota
Rice County Community
Health Service - Minnesota
Norman/Mahnomen Public
Health - Minnesota
Scott County Public Health Minnesota
Sibley County Public Health Minnesota
Sherburne County
HHS/Public Health Unit Minnesota
Kanabec County Public
Health - Minnesota
Le Sueur County Public
Health Nursing Service Minnesota
Grant County Health Office Oregon
Harney County Health
Department - Oregon
Lake County Public Health
Department - Oregon
Hood River County Health
Department - Oregon
Lane County Public Health
Department - Oregon
Jefferson County Health
Department - Oregon
Lincoln County Health and
Human Services - Oregon
Josephine County Public
Health Department - Oregon
Linn County Health
Department - Oregon
Klamath County Department
of Public Health - Oregon
Morrow County Health
Department - Oregon
Multnomah County Health
Department - Oregon
Polk County Public Health Oregon
Tillamook County Health
Department - Oregon
Umatilla County Public Health
Department - Oregon
Union County Health
Department - Oregon
Wallowa County Health
Department - Oregon
Washington County
Department of Health and
Human Services - Oregon
Jackson County Health and
Human Services - Oregon
Wheeler County Health
Department - Oregon
Yamhill County HandH ServPublic Health - Oregon
Klamath Tribal Health and
Family Services - Oregon
Malheur County Health
Department - Oregon
North Central Public Health
District - Oregon
Allegheny County Health
Department - Pennsylvania
Allentown City Bureau of
Health - Pennsylvania
Bethlehem City Bureau of
Health - Pennsylvania
Bucks County Department of
Health - Pennsylvania
Chester County Health
Department - Pennsylvania
Cumberland County State
Health Center - Pennsylvania
Erie County Department of
Health - Pennsylvania
117
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Fannin County Health Center Georgia
Fayette County Health
Department - Georgia
Glynn County Health Department
- Georgia
Forsyth County Health
Department - Georgia
Gordon County Health
Department - Georgia
Franklin County Health
Department - Georgia
Grady County Health Department
- Georgia
District 3, Unit 2: Fulton County
Health District - Georgia
Greene County Health
Department - Georgia
Gilmer County Health
Department - Georgia
District 3, Unit 4: East Metro
Health District - Georgia
Habersham County Health
Department - Georgia
Hall County Health Department Georgia
Hancock County Health
Department - Georgia
Haralson Community Health
Services - Georgia
Harris County Health Department
- Georgia
Hart County Health Department Georgia
District 8, Unit 2, Southwest
Health District - Georgia
Houston County Health
Department - Georgia
Heard County Health Department
- Georgia
Henry County Health Department
- Georgia
Irwin County Health Department
- Georgia
Jackson County Health
Department - Georgia
Jasper County Health Department
- Georgia
Jeff Davis County Health
Department - Georgia
Jefferson County Board of Health
- Georgia
Jenkins County Health
Department - Georgia
Johnson County Health
Department - Georgia
Jones County Health Department
- Georgia
Lamar County Health Department
- Georgia
Lanier County Health Department
- Georgia
Lake County Health
Department - Minnesota
Stearns County Public Health
Division - Minnesota
Carlton-Cook-Lake-St. Louis
Community Health Board Minnesota
LakeWood Nursing Service Minnesota
Nicollet County Public Health
Nursing Service - Minnesota
Todd County Public Health Minnesota
Wabasha Community Health
Service - Minnesota
Red Lake Comprehensive
Health Services - Minnesota
Waseca County Public Health
Services - Minnesota
McLeod County Public
Health Nursing Service Minnesota
Meeker County Public Health
Department - Minnesota
Kittson Memorial Home
Healthcare - Minnesota
Marshall County Public
Health Nursing Service Minnesota
Roseau County Home Health
Care/LifeCare Public Health Minnesota
Inter-County Public Health
Nursing - Minnesota
Redwood County Public
Health Services - Minnesota
Aitkin County Health and
Human Services - Minnesota
Benton County Human
Services - Minnesota
Pine County Public Health Minnesota
Itasca County Health and
Human Services - Minnesota
Beltrami County Public
Health Nursing Service Minnesota
Koochiching County
Community Health Minnesota
Clearwater County Nursing
Service - Minnesota
Brown-Nicollet Community
Health Services - Minnesota
St. Joseph's Area Health
Services - Minnesota
Morrison-Todd-Wadena
Community Health Board Minnesota
Morrison County Public
Health - Minnesota
Forest County State Health
Center - Pennsylvania
Lancaster County State
Health Center - Pennsylvania
Lebanon County State Health
Center - Pennsylvania
Wilkes-Barre City Health
Department - Pennsylvania
Montgomery County
Department of Health Pennsylvania
Northcentral District Office Pennsylvania
Northwest District Office Pennsylvania
Philadelphia Department of
Public Health - Pennsylvania
Southcentral District Office Pennsylvania
Southeast District Offiice Pennsylvania
Southwest District Office Pennsylvania
York City Bureau of Health Pennsylvania
Adams County State Health
Center - Pennsylvania
Armstrong County State
Health Center - Pennsylvania
Centre County State Health
Center - Pennsylvania
Beaver County State Health
Center - Pennsylvania
Bedford County State Health
Center - Pennsylvania
Blair County State Health
Center - Pennsylvania
Clarion County State Health
Center - Pennsylvania
Bradford County State Health
Center - Pennsylvania
Clearfield County State
Health Center - Pennsylvania
Cambria County State Health
Center - Pennsylvania
Clinton County State Health
Center - Pennsylvania
Carbon County State Health
Center - Pennsylvania
Columbia County State
Health Center - Pennsylvania
Crawford County State
Health Center - Pennsylvania
Dauphin County State Health
Center - Pennsylvania
Delaware County State
Health Center - Pennsylvania
Elk County State Health
Center - Pennsylvania
Fayette County State Health
Center - Pennsylvania
Franklin County State Health
Center - Pennsylvania
118
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Laurens County Health
Department - Georgia
Lee County Health Department Georgia
Liberty County Health
Department - Georgia
Lincoln County Health
Department - Georgia
Long County Health Department Georgia
Lowndes County Health
Department - Georgia
Lumpkin County Health
Department - Georgia
Macon County Health
Department - Georgia
Madison County Health
Department - Georgia
Marion County Health
Department - Georgia
McDuffie County Health
Department - Georgia
McIntosh County Health
Department - Georgia
Meriwether County Health
Department - Georgia
Miller County Health Department
- Georgia
Mitchell County Health
Department - Georgia
Monroe County Health
Department - Georgia
Montgomery County Health
Department - Georgia
Morgan County Health
Department - Georgia
Murray County Health
Department - Georgia
Newton County Health
Department - Georgia
Oconee County Health
Department - Georgia
Oglethorpe County Health
Department - Georgia
Paulding County Health
Department - Georgia
Peach County Health Department
- Georgia
Pickens County Health
Department - Georgia
Pierce County Health Department
- Georgia
Pike County Health Department Georgia
Polk County Health Department Georgia
Pulaski County Health
Department - Georgia
Putnam County Health
Department - Georgia
Quitman County Health
Department; District 7-0 Georgia
Adair County Health
Department/Home Health
Agency - Missouri
Wadena County Public
Health - Minnesota
Andrew County Health
Department - Missouri
Cass County Health Services Minnesota
Atchison County Health
Department - Missouri
Audrain City-County Health
Unit - Missouri
Barry County Health
Department - Missouri
Barton County Health
Department - Missouri
Bates County Health Center Missouri
Benton County Health
Department - Missouri
Bollinger County Health
Department - Missouri
Butler County Health
Department - Missouri
Caldwell County Health
Department - Missouri
Callaway County Health
Department - Missouri
Camden County Health
Department - Missouri
Cape Girardeau County
Public Health Center Missouri
Carroll County Health
Department - Missouri
Carter County Health Center
- Missouri
Crawford County Nursing
Service/Health Department Missouri
Cass County Health
Department - Missouri
Chariton County Health
Center - Missouri
Dade County Health
Department - Missouri
Christian County Health
Department - Missouri
Dallas County Health
Department - Missouri
Clark County Health
Department - Missouri
Daviess County Health
Department - Missouri
Clay County Public Health
Center - Missouri
Dent County Health Center Missouri
Clinton County Health
Department - Missouri
Douglas County Health
Department - Missouri
Fulton County State Health
Center - Pennsylvania
Jefferson County State Health
Center - Pennsylvania
Greene County State Health
Center - Pennsylvania
Huntingdon County State
Health Center - Pennsylvania
Juniata County State Health
Center - Pennsylvania
Indiana County State Health
Center - Pennsylvania
Lackawanna County State
Health Center - Pennsylvania
Lawrence County State
Health Center - Pennsylvania
Lehigh County State Health
Center - Pennsylvania
Luzerne County State Health
Center - Pennsylvania
Lycoming County State
Health Center - Pennsylvania
McKean County State Health
Center - Pennsylvania
Mercer County State Health
Center - Pennsylvania
Mifflin County State Health
Center - Pennsylvania
Monroe County State Health
Center - Pennsylvania
Perry County State Health
Center - Pennsylvania
Montour County State Health
Center - Pennsylvania
Pike County State Health
Center - Pennsylvania
Northampton County State
Health Center - Pennsylvania
Potter County State Health
Center - Pennsylvania
Northumberland County
State Health Center Pennsylvania
Schuylkill County State Health
Center - Pennsylvania
Northeast District Office Pennsylvania
Snyder County State Health
Center - Pennsylvania
Somerset County State
Health Center - Pennsylvania
Susquehanna County State
Health Center - Pennsylvania
Tioga County State Health
Center - Pennsylvania
Union County State Health
Center - Pennsylvania
Venango County State Health
Center - Pennsylvania
Warren County State Health
Center - Pennsylvania
Washington County State
Health Center - Pennsylvania
119
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Rabun County Health Department
- Georgia
Randolph County Health
Department - Georgia
Richmond County Health
Department - Georgia
Rockdale County Health
Department - Georgia
Schley County Health Department
- Georgia
Seminole County Health
Department - Georgia
District 5, Unit 1: South Central
District - Georgia
Spalding County Health
Department - Georgia
Stephens County Health
Department - Georgia
Stewart County Health
Department - Georgia
Sumter County Health
Department - Georgia
Talbot County Health Department
- Georgia
Taliaferro County Health
Department - Georgia
Tattnall County Health
Department - Georgia
Taylor County Health Department
- Georgia
Telfair County Health Department
- Georgia
Terrell County Health
Department - Georgia
Thomas County Health
Department - Georgia
Tift County Health Department Georgia
Toombs County Health
Department - Georgia
Towns County Health
Department - Georgia
Treutlen County Health
Department - Georgia
Troup County Health Department
- Georgia
Turner County Health
Department - Georgia
Twiggs County Health
Department - Georgia
Union County Health Department
- Georgia
Upson County Health
Department - Georgia
Walker County Health
Department - Georgia
Walton County Health
Department - Georgia
Ware County Health Department
- Georgia
Warren County Health
Department - Georgia
Cole County Health
Department - Missouri
Dunklin County Health
Department - Missouri
Columbia/Boone County
Health Department Missouri
Franklin County Department
of Health - Missouri
Cooper County Public Health
Center - Missouri
Gasconade County Health
Department - Missouri
Grundy County Health
Department - Missouri
Harrison County Health
Department - Missouri
Henry County Health Center
- Missouri
Hickory County Health
Department - Missouri
Holt County Health
Department - Missouri
Howard County Health
Department - Missouri
Independence City Health
Department - Missouri
Iron County Health
Department - Missouri
Jackson County Health
Department - Missouri
Jasper County Health
Department - Missouri
Jefferson County Health
Department - Missouri
Johnson County Community
Health Services - Missouri
Livingston County Health
Center - Missouri
Joplin City Health
Department - Missouri
Kansas City Health
Department - Missouri
Macon County Health
Department - Missouri
Knox County Health
Department - Missouri
Madison County Health
Department - Missouri
Laclede County Health
Department - Missouri
Marion County Health
Department and Home
Health Agency - Missouri
Lafayette County Health
Department - Missouri
McDonald County Health
Department - Missouri
Mercer County Health
Department - Missouri
Lawrence County Health
Department - Missouri
Springfield Township Pennsylvania
Wayne County State Health
Center - Pennsylvania
Westmoreland County State
Health Center - Pennsylvania
Northampton County Board
of Health - Pennsylvania
Wyoming County State
Health Center - Pennsylvania
Berks County Community
Health Project - Berks Visiting
Nurse Association Pennsylvania
York County State Health
Center - Pennsylvania
Narragansett Indian Tribe Rhode Island
Region 1 - Public Health
Regional Office - South
Carolina
Region 2 - Public Health
Regional Office - South
Carolina
Region 5 - Public Health
Regional Office - South
Carolina
Region 3 - Public Health
Regional Office - South
Carolina
Region 8 - Public Health
Regional Office - South
Carolina
Region 7 - Public Health
Regional Office - South
Carolina
Flandreau Santee Sioux Tribe
Health Clinic - South Dakota
Region 6 - Public Health
Regional Office - South
Carolina
Region 4 - Public Health
Regional Office - South
Carolina
Miner County - South Dakota
Lake County Health
Department - South Dakota
Edmunds County Public
Health Services - South
Dakota
Sioux Falls City Health
Department - South Dakota
Tripp County Public Health
Services - South Dakota
Hand County Public Health
Services - South Dakota
Meade County - South
Dakota
Harding County, Buffalo
Regional Medical Clinic South Dakota
Perkins County - South
Dakota
120
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Washington County Health
Department - Georgia
Wayne County Health
Department - Georgia
Webster County Health
Department - Georgia
Wheeler County Health
Department - Georgia
White County Health Department
- Georgia
Whitfield County Health
Department - Georgia
Wilcox County Health
Department - Georgia
Wilkes County Health
Department - Georgia
Wilkinson County Health
Department - Georgia
Worth County Health
Department - Georgia
Screven County Health
Department - Georgia
District 4: LaGrange Health
District - Georgia
District 1, Unit 2: North Georgia
Health District - Georgia
District 3, Unit 1: Cobb-Douglas
Health District - Georgia
District 3, Unit 3: Clayton County
Health District - Georgia
District 5, Unit 2: North Central
District - Georgia
District 6: East Central Health
District - Georgia
District 7: West Central District Georgia
District 8, Unit 1: South Health
District - Georgia
District 9, Unit 1: Coastal Health
District - Georgia
District 9, Unit 2: Southeast
Health District - Georgia
District 10: Northeast Health
District - Georgia
Hawaii District Health Office Hawaii
Kauai District Health Office Hawaii
Maui District Health Office Hawaii
Honolulu Department of Health Hawaii
Kalawao District Health Office Hawaii
Adair County Home Care - Iowa
Adams County/Alegent Health
Family Home Care - Iowa
Allamakee County / Veterans
Memorial Hospital Community
and Home Care - Iowa
Appanoose County Public Health
Nursing Service - Iowa
Miller County Health
Department - Missouri
Lewis County Home Health
Agency - Missouri
Mississippi County Health
Department - Missouri
Lincoln County Health
Department - Missouri
Moniteau County Health
Center - Missouri
Linn County Health Center Missouri
Monroe County Health
Department - Missouri
Montgomery County Health
Department - Missouri
Morgan County Health
Department - Missouri
New Madrid County Health
Department - Missouri
Newton County Health
Department - Missouri
Nodaway County Health
Department - Missouri
Oregon County Health
Department - Missouri
Ozark County Health Center Missouri
Pemiscot County Health
Department - Missouri
Perry County Health
Department - Missouri
Pettis County Health Center Missouri
Phelps/Maries County Health
Department - Missouri
Ripley County Public Health
Center - Missouri
Pike County Nursing Service Missouri
Platte County Health
Department - Missouri
Saline County Health
Department - Missouri
Polk County Health Center Missouri
Schuyler County Health
Department - Missouri
Pulaski County Health
Department - Missouri
Scotland County Health
Department - Missouri
Putnam County Health
Department - Missouri
Shannon County Health
Department - Missouri
Ralls County Health
Department and Home
Health Agency - Missouri
Shelby County Health
Department - Missouri
Randolph County Health
Department - Missouri
Butte County - South Dakota
Lawrence County - South
Dakota
Spink County - South Dakota
Ziebach County - South
Dakota
Dewey County - South
Dakota
Beadle County - South
Dakota
Clay County - South Dakota
Day County - South Dakota
Brown County Community
Health Center - South Dakota
Marshall County - South
Dakota
Faulk County - South Dakota
Kingsbury County - South
Dakota
Jerauld County - South
Dakota
Sanborn County - South
Dakota
Brule County - South Dakota
Aurora County - South
Dakota
Davison County - South
Dakota
Hanson County - South
Dakota
Bon Homme County - South
Dakota
Douglas County Memorial
Hospital - South Dakota
Hutchinson County Public
Health Services - South
Dakota
Turner County Public Health
Services - South Dakota
Gregory County - South
Dakota
Lyman County - South Dakota
Charles Mix County - South
Dakota
Jones County - South Dakota
Haakon County - South
Dakota
Stanley County - South
Dakota
Hughes County - South
Dakota
Potter County - South Dakota
Roberts County - South
Dakota
Lincoln County - South
Dakota
Grant County - South Dakota
Codington County - South
Dakota
Hamlin County - South
Dakota
McCook County - South
Dakota
121
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Audubon County Public Health
Nursing Service - Iowa
Benton County / Virginia Gay
Hospital Home Health Agency Iowa
Black Hawk County Health
Department - Iowa
Boone County / Hospital Home
Care Services - Iowa
Henry County Public
Health/Health Center - Iowa
Buchanan County Public Health
Department - Iowa
Buena Vista County Public Health
and Home Care - Iowa
Butler County Public Health Iowa
Calhoun County Public Health Iowa
Cass County / CCMH Home
Care/Hospice - Iowa
Cedar County Public Health
Nursing Service - Iowa
Cerro Gordo County Public Health
Department - Iowa
Cherokee County Home
Choice/Hospice/Public Health Iowa
Chickasaw County Public Health Iowa
Clarke County Public Health
Department - Iowa
Clay County / Spencer Hospital
Public Health - Iowa
Clayton County Visiting Nurses
Association - Iowa
Clinton County / Genesis Visiting
Nurses Association & Hospice Iowa
Council Bluffs City Health
Department - Iowa
Jones County / Community
Health of Jones County - Iowa
Crawford County Home Health
and Hospice Agency - Iowa
Dallas County Public Health
Nursing Service - Iowa
Davis County Hospital Home and
Community Health - Iowa
Decatur County Public Health and
Home Care - Iowa
Delaware County Public Health Iowa
Des Moines County Public Health
- Iowa
Dickinson County / Lakes
Regional Healthcare - Iowa
City of Dubuque Health Services
Department - Iowa
Dubuque County Health
Department - Iowa
Madison County Public Health Iowa
Springfield-Greene County
Health Department Missouri
Ray County Health
Department - Missouri
St. Charles County Health
Department - Missouri
Reynolds County Health
Center - Missouri
Scott County Health
Department - Missouri
Ste. Genevieve County
Health Department Missouri
St. Joseph-Buchanan County
Health Department Missouri
St. Louis City Department of
Health - Missouri
St. Louis County Department
of Health - Missouri
Stoddard County Public
Health Center - Missouri
Stone County Health
Department - Missouri
Sullivan County Health
Department - Missouri
Taney County Health
Department - Missouri
Texas County Health
Department - Missouri
Tri-County Health
Department - Missouri
Vernon County Health
Department - Missouri
Washington County Health
Department - Missouri
Wayne County Health Center
- Missouri
Eastern District Health
Office/Missouri Department
of Health - Missouri
St. Francois County Health
Center - Missouri
Webster County Health Unit
- Missouri
Northeastern District Health
Office/Missouri Department
of Health - Missouri
Wright County Health
Department - Missouri
Northwestern District Health
Office/Missouri Dept. of
Health - Missouri
Cedar County Health
Department - Missouri
Southeastern District Health
Office/Missouri Dept. of
Health - Missouri
Southwestern District Health
Office/Missouri Dept. of
Health - Missouri
McPherson County Public
Health Services - South
Dakota
Deuel County Community
Memorial Services - South
Dakota
Clark County - South Dakota
Minnehaha County - South
Dakota
Brookings County - South
Dakota
Moody County Public Health
Services - South Dakota
Pennington County - South
Dakota
Jackson County - South
Dakota
Bennett County - South
Dakota
Shannon County Public
Health Service Hospital South Dakota
Fall River County - South
Dakota
Custer County - South Dakota
Buffalo County Office (Indian
Health Service Clinic) - South
Dakota
Union County - South Dakota
Walworth County Public
Health Services - South
Dakota
Campbell County Clinic South Dakota
Yankton County - South
Dakota
Charles Mix County - Platte
Clinic - South Dakota
Sully County - Onida Clinic South Dakota
Corson County Clinic - South
Dakota
Lawrence County - Spearfish
Community Health Clinic South Dakota
Meade County - Faith
Community Health Services South Dakota
Mellette County Health Clinic
- South Dakota
Perkins County - Lemmon
Community Health Services South Dakota
DBA Mission Medical Clinic South Dakota
South Dakota Region 6 Mitchell - South Dakota
South Dakota Region 4 Watertown - South Dakota
South Dakota Region 7 Rapid City - South Dakota
South Dakota Region 1 Sturgis - South Dakota
122
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Emmet County Public Health Iowa
Fayette County / Palmer Home
Agency - Iowa
Webster County Public Health
Agency - Iowa
Franklin County Public Health
Nursing Service - Iowa
Greene County Medical Center
Public Health - Iowa
Grundy County Public Health Iowa
Guthrie County Public Health
Nursing Service - Iowa
Hancock County Public Health
Services - Iowa
Hardin County / Greenbelt Home
Care - Iowa
Howard County / Regional Health
Service of Howard County - Iowa
Ida County / Horn Memorial
Hospital Community Health
Services - Iowa
Iowa County Health Department Iowa
Jefferson County Public Health Iowa
Johnson County Public Health Iowa
Keokuk County Public Health Iowa
Kossuth County Regional Health
Center/Community Health - Iowa
Lee County Health Department,
Community Nursing and EH
Services - Iowa
Louisa County Public Health Iowa
Lucas County Public Health
Nursing Service - Iowa
Lyon County Health Services Iowa
Mahaska County Partnership
Community Health - Iowa
Marion County / Community
Health Services of Marion County
- Iowa
Mills County Public Health
Department - Iowa
Monona County Public Health
Nursing Service - Iowa
Monroe County Public Health Iowa
Muscatine County/Unity Health
Care - Iowa
O'Brien County Public Health Iowa
Osceola County Health Service Iowa
City of Ottumwa Health
Department - Iowa
Page County Public Health Service
- Iowa
Warren County Health
Department - Missouri
Howell County Health
Department - Missouri
St. Clair County Health
Department - Missouri
Cameron Area Health
Office/Missouri Department
of Health - Missouri
Columbia Area Health Office
- Missouri
Cape Girardeau Area Health
Office/Missouri Department
of Health - Missouri
Osage County Health
Department - Missouri
Adams County Health
Department - Mississippi
Alcorn County Health
Department - Mississippi
Amite County Health
Department - Mississippi
Benton County Health
Department - Mississippi
Bolivar County Health
Department - Mississippi
Calhoun County Health
Department - Mississippi
Carroll County Health
Department - Mississippi
Chickasaw County Health
Department - Mississippi
Choctaw County Health
Department - Mississippi
Claiborne County Health
Department - Mississippi
Clarke County Health
Department - Mississippi
Clay County Health
Department - Mississippi
Coahoma County Health
Department - Mississippi
Hancock County Health
Department - Mississippi
Public Health District 9 Coastal/Plains / Mississippi
Department of Health Mississippi
Copiah County Health
Department - Mississippi
Harrison County Health
Department - Mississippi
Covington County Health
Department - Mississippi
Public Health District 3 Delta/Hills / Mississippi
Department of Health Mississippi
DeSoto County Health
Department - Mississippi
Hinds County Health
Department - Mississippi
Region 2 Pierre - South
Dakota
Black Hills Center American
Indian Health - South Dakota
Region 3 Aberdeen - South
Dakota
Anderson County Health
Department - Tennessee
South Dakota Region 5 Sioux Falls - South Dakota
Bedford County Health
Department - Tennessee
Benton County Health
Department - Tennessee
Bledsoe County Health
Department - Tennessee
Blount County Health
Department - Tennessee
Bradley County Health
Department - Tennessee
Campbell County Health
Department - Tennessee
Cannon County Health
Department - Tennessee
Claiborne County Health
Department - Tennessee
Carroll County Health
Department - Tennessee
Carter County Health
Department - Tennessee
Clay County Health
Department - Tennessee
Chattanooga-Hamilton
County Health Department Tennessee
Cocke County Health
Department - Tennessee
Cheatham County Health
Department - Tennessee
Coffee County Health
Department - Tennessee
Chester County Health
Department - Tennessee
Crockett County Health
Center - Tennessee
Cumberland County Health
Department - Tennessee
Metro Public Health
Department - Tennessee
Decatur County Health
Department - Tennessee
Dekalb County Health
Department - Tennessee
Dickson County Health
Department - Tennessee
Hawkins County Health
Department / Church Hill
Office - Tennessee
Dyer County Health
Department - Tennessee
Franklin County Health
Department - Tennessee
123
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Palo Alto County Community
Health Service - Iowa
Pocahontas County Nursing and
Health Service - Iowa
Polk County Health Department Iowa
Pottawattamie County/Visiting
Nurse Association - Iowa
Ringgold County Public Health
Nursing Agency - Iowa
Sac County Public Health Nursing
- Iowa
Scott County Health Department
- Iowa
Sioux County/Community Health
Partners - Iowa
Woodbury County/Siouxland
District Health Department - Iowa
HOMEWARD, Story County Mary Greely Medical Center Iowa
Tama County Public Health and
Home Care - Iowa
Taylor County Public Health
Agency - Iowa
Van Buren County Public Health
Nursing Service - Iowa
Wapello County Public Health Iowa
Washington County Public Health
and Home Care - Iowa
Wayne County Public Health Iowa
Winnebago County Public Health
Nursing Service - Iowa
Winneshiek County Public Health
Nursing Service - Iowa
Worth County Public Health Iowa
Wright County Public Health
Nursing Service/Hospice for
Wright County - Iowa
Hamilton County Public Health Iowa
Jackson County Regional Health
Center - Iowa
Floyd County Public Health/Home
Health Care - Iowa
Union County/Greater
Community Hospital Outreach
Services - Iowa
Harrison County Public Health Iowa
Mitchell County Home Health
Care - Iowa
Southwest Iowa Home Health Iowa
Carroll County / St. Anthony
Home Health Agency - Iowa
Bremer County Home Care - Iowa
Marshall Medical and Surgical
Center Home Care Plus - Iowa
Forrest County Health
Department - Mississippi
Holmes County Health
Department - Mississippi
Franklin County Health
Department - Mississippi
Humphreys County Health
Department - Mississippi
George County Health
Department - Mississippi
Sharkey/Issaquena County
Health Department Mississippi
Itawamba County Health
Department - Mississippi
Greene County Health
Department - Mississippi
Jackson County Health
Department - Mississippi
Grenada County Health
Department - Mississippi
Jasper County Health
Department - Mississippi
Jefferson Davis County
Health Department Mississippi
Jefferson County Health
Department - Mississippi
Jones County Health
Department - Mississippi
Kemper County Health
Department - Mississippi
Lafayette County Health
Department - Mississippi
Lamar County Health
Department - Mississippi
Lawrence County Health
Department - Mississippi
Leake County Health
Department - Mississippi
Lee County Health
Department - Mississippi
Leflore County Health
Department - Mississippi
Oktibbeha County Health
Department - Mississippi
Lincoln County Health
Department - Mississippi
Lowndes County Health
Department - Mississippi
Panola County Health
Department - Mississippi
Madison County Health
Department - Mississippi
Pearl River County Health
Department - Mississippi
Marion County Health
Department - Mississippi
Perry County Health
Department - Mississippi
Marshall County Health
Department - Mississippi
East Region, Tennessee
Department of Health Tennessee
Gibson County Health
Department - Tennessee
Fayette County Health
Department - Tennessee
Giles County Health
Department - Tennessee
Fentress County Health
Department - Tennessee
Grainger County Health
Department - Tennessee
Greene County Health
Department - Tennessee
Grundy County Health
Department - Tennessee
Hamblen County Health
Department - Tennessee
Hancock County Health
Department - Tennessee
Hardeman County Health
Department - Tennessee
Hardin County Health
Department - Tennessee
Hawkins County Health
Department - Tennessee
Haywood County Health
Department - Tennessee
Houston County Health
Department - Tennessee
Henderson County Health
Department - Tennessee
Humphreys County Health
Department - Tennessee
Henry County Health
Department - Tennessee
Jackson County Health
Department - Tennessee
Hickman County Health
Department - Tennessee
Jackson - Madison County
Health Department Tennessee
Jefferson County Health
Department - Tennessee
Johnson County Health
Department - Tennessee
Knox County Health
Department - Tennessee
Lake County Health
Department - Tennessee
Lauderdale County Health
Department - Tennessee
Lawrence County Health
Department - Tennessee
Marshall County Health
Department - Tennessee
Lewis County Health District Tennessee
Maury County Health
Department - Tennessee
124
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Montgomery County Public
Health Nursing Service - Iowa
Floyd Valley Community Health
Service - Iowa
Poweshiek County/Grinnell
Regional Home Care - Iowa
Shelby County/Myrtue Memorial
Hospital Home and Public Health
- Iowa
Warren County Health Services Iowa
Region 6/Iowa Department of
Public Health - Iowa
Region 4/Iowa Department of
Public Health - Iowa
Region 5/Iowa Department of
Public Health - Iowa
Region 3/Iowa Department of
Public Health - Iowa
Region 2/Iowa Department of
Public Health - Iowa
Region 1/Iowa Department of
Public Health - Iowa
Jasper County Home Care Aides Iowa
Brown County Health
Department - Illinois
Unity Public Health - Iowa
Bureau County Health
Department - Illinois
Central District Health
Department (Region 4) - Idaho
Calhoun County Health
Department - Illinois
Eastern Idaho Public Health
District (Region 7) - Idaho
Cass County Health Department Illinois
North Central District Health
Department (Region 2) - Idaho
Champaign-Urbana Public Health
District - Illinois
Panhandle Health District (Region
1) - Idaho
Southwest District Health
Department (Region 3) - Idaho
Chicago Department of Public
Health - Illinois
South Central Public Health
District (PHD 5) - Idaho
Christian County Health
Department - Illinois
Clay County Health Department Illinois
Southeastern District Health
Department (Region 6) - Idaho
Coles County Health Department
- Illinois
Adams County Health
Department - Illinois
Cook County Department of
Public Health - Illinois
Pike County Health
Department - Mississippi
Monroe County Health
Department - Mississippi
Pontotoc County Health
Department - Mississippi
Montgomery County Health
Department - Mississippi
Prentiss County Health
Department - Mississippi
Neshoba County Health
Department - Mississippi
Quitman County Health
Department - Mississippi
Newton County Health
Department - Mississippi
Rankin County Health
Department - Mississippi
Noxubee County Health
Department - Mississippi
Scott County Health
Department - Mississippi
Simpson County Health
Department - Mississippi
Smith County Health
Department - Mississippi
Stone County Health
Department - Mississippi
Sunflower County Health
Department - Mississippi
Tallahatchie County Health
Department - Mississippi
Tate County Health
Department - Mississippi
Tippah County Health
Department - Mississippi
Tishomingo County Health
Department - Mississippi
Tunica County Health
Department - Mississippi
Lauderdale County Health
Department - Mississippi
Union County Health
Department - Mississippi
Walthall County Health
Department - Mississippi
Public Health District 6 - East
Central/Mississippi
Department of Health Mississippi
Warren County Health
Department - Mississippi
Public Health District 2 Northeast/Mississippi
Department of Health Mississippi
Washington County Health
Department - Mississippi
Public Health District 1 Northwest/Mississippi
Department of Health Mississippi
Lincoln County Health
Department - Tennessee
McMinn County Health
Department - Tennessee
Loudon County Health
Department - Tennessee
McNairy County Health
Department - Tennessee
Macon County Health
Department - Tennessee
Meigs County Health
Department - Tennessee
Marion County Health
Department - Tennessee
Shelby County Health
Department - Tennessee
Monroe County Health
Department - Tennessee
Montgomery County Health
Department - Tennessee
Moore County Health
Department - Tennessee
Morgan County Health
Department - Tennessee
Obion County Health
Department - Tennessee
Overton County Health
Department - Tennessee
Perry County Health
Department - Tennessee
Putnam County Health
Department - Tennessee
Pickett County Health
Department - Tennessee
Polk County Health
Department - Tennessee
Rhea County Health
Department - Tennessee
Roane County Health
Department - Tennessee
Robertson County Health
Department - Tennessee
Rutherford County Health
Department - Tennessee
Scott County Health
Department - Tennessee
Sequatchie County Health
Department - Tennessee
Sevier County Health
Department - Tennessee
Smith County Health
Department - Tennessee
Union County Health
Department - Tennessee
Stewart County Health
Department - Tennessee
Sullivan County Regional
Health Department Tennessee
Van Buren County Health
Department - Tennessee
Sumner County Health
Department - Tennessee
125
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Bond County Health Department
- Illinois
Cumberland County Health
Department - Illinois
Boone County Department of
Public Health - Illinois
DeKalb County Health
Department - Illinois
DeWitt-Piatt Bi County Health
Department - Illinois
Douglas County Health
Department - Illinois
DuPage County Health
Department - Illinois
East Side Health District - Illinois
Effingham County Health
Department - Illinois
Egyptian Health Department Illinois
Evanston Department of Health
and Human Services - Illinois
Jasper County Health Department
- Illinois
Fayette County Health
Department - Illinois
Jefferson County Health
Department - Illinois
Jersey County Health Department
- Illinois
Jo Daviess County Health
Department - Illinois
Kane County Health Department Illinois
Kankakee County Health
Department - Illinois
Kendall County Health
Department - Illinois
Knox County Health Department Illinois
LaSalle County Health
Department - Illinois
Ford-Iroquois Public Health
Department - Illinois
Lake County Health Department Illinois
Franklin-Williamson Bi-County
Health Department - Illinois
Lawrence County Health
Department - Illinois
Fulton County Health
Department - Illinois
Lee County Health Department Illinois
Greene County Health
Department - Illinois
Livingston County Health
Department - Illinois
Grundy County Health
Department - Illinois
Logan County Department of
Public Health - Illinois
Hamilton County Health
Department - Illinois
Wayne County Health
Department - Mississippi
Public Health District 8 Southeast/Mississippi
Department of Health Mississippi
Webster County Health
Department - Mississippi
Wilkinson County Health
Department - Mississippi
Public Health District 7 Southwest/Mississippi
Department of Health Mississippi
Winston County Health
Department - Mississippi
Public Health District 4 Tombigbee/Mississippi
Department of Health Mississippi
Yalobusha County Health
Department - Mississippi
Public Health District 5 West Central/Mississippi
Department of Health Mississippi
Beaverhead County Public
Health Department Montana
Yazoo County Health
Department - Mississippi
Big Horn County Health
Department - Montana
Attala County Health
Department - Mississippi
Blaine County Health
Department - Montana
Broadwater County Health
Department - Montana
Silver Bow-Butte City-County
Health Department Montana
Carbon County Health
Department - Montana
Carter County Health
Department - Montana
Cascade City-County Health
Department - Montana
Chouteau County Health
Department - Montana
Custer County Health
Department - Montana
Daniels County - Montana
Dawson County Health
Department - Montana
Deer Lodge County Health
Department - Montana
Lake County Health
Department - Montana
Fallon County Health
Department - Montana
Warren County Health
Department - Tennessee
Tipton County Health
Department - Tennessee
Washington County Health
Department - Tennessee
Trousdale County Health
Department - Tennessee
Wayne County Health
Department - Tennessee
Unicoi County Health
Department - Tennessee
Weakley County Health
Department - Tennessee
White County Health
Department - Tennessee
Williamson County Health
Department - Tennessee
Wilson County Health
Department - Tennessee
Northeast Region, Tennessee
Department of Health Tennessee
Southeast Region, Tennessee
Department of Health Tennessee
Upper Cumberland Region,
Tennessee Department of
Health - Tennessee
Mid-Cumberland Region,
Tennessee Department of
Health - Tennessee
Abilene-Taylor County Public
Health District - Texas
South Central Region,
Tennessee Department of
Health - Tennessee
West Tennessee Region,
Tennessee Department of
Health - Tennessee
Andrews County Health
Department - Texas
Angelina County/Cities
Health District - Texas
Arlington Environmental
Health Department - Texas
Austin/Travis County Health
and Human Services - Texas
Beaumont City Health
Department - Texas
Bell County Public Health
District - Texas
Town of Pampa Department
of Sanitation - Texas
Frisco City Health
Department - Texas
Lake Dallas Health
Department - Texas
Garland City Health
Department - Texas
Rowlett City Health
Department - Texas
126
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Macon County Health
Department - Illinois
Hancock County Health
Department - Illinois
Henderson County Health
Department - Illinois
Henry and Stark County Health
Department - Illinois
Jackson County Health
Department - Illinois
Macoupin County Health
Department - Illinois
Peoria City/County Health
Department - Illinois
Mason County Health
Department - Illinois
Carroll County Health
Department - Illinois
McDonough County Health
Department - Illinois
McHenry County Department of
Health - Illinois
Pike County Health Department Illinois
McLean County Health
Department - Illinois
Putnam County Health
Department - Illinois
Menard County Health
Department - Illinois
Rock Island County Health
Department - Illinois
Mercer County Health
Department - Illinois
Sangamon County Health
Department - Illinois
Randolph County Health
Department - Illinois
Schuyler County Health
Department - Illinois
Montgomery County Health
Department - Illinois
Shelby County Health
Department - Illinois
Morgan County Health
Department - Illinois
Skokie Health Department Illinois
Oak Park Department of Public
Health - Illinois
Southern Seven Health
Department - Illinois
St. Clair County Health
Department - Illinois
Ogle County Health Department Illinois
Clark County Health Department Illinois
Stephenson County Health
Department - Illinois
Perry County Health Department
- Illinois
Lewis and Clark City-County
Health Department Montana
Central Montana Health
District/Fergus County
Health Department Montana
Liberty County Health
Department - Montana
Flathead City-County Health
Department - Montana
Lincoln County Health
Department - Montana
Gallatin City-County Health
Department - Montana
Madison County Health
Department - Montana
Garfield County Health
Department - Montana
McCone County Health
Department - Montana
Glacier County Health
Department - Montana
Meagher County Health
Department - Montana
Granite County Health
Department - Montana
Hill County Health
Department - Montana
Mineral County Health
Department - Montana
Missoula City-County Health
Department - Montana
Jefferson County Health
Department - Montana
Park County Health
Department - Montana
Phillips County Health
Department - Montana
Pondera County Health
Department - Montana
Powder River County Health
Department - Montana
Powell County Health
Department - Montana
Prairie County Health
Department - Montana
Ravalli County Public Health
Nursing Department Montana
Richland County Health
Department - Montana
Roosevelt County Health
Department - Montana
Rosebud County Health
Department - Montana
Sanders County Health
Department - Montana
Sheridan County Health
Department - Montana
Crow Tribal Health
Department - Montana
Town of Flower Mound
Health Department - Texas
Mesquite City Health
Department - Texas
Ellis County Human Services
Department - Texas
Farmers Branch City Health
Department - Texas
Ennis City Health Department
- Texas
Waxahachie City Health
Department - Texas
Coppell City Health
Department - Texas
Granbury City - Code
Enforcement - Texas
City of the Colony Health
Department - Texas
Cleburne City - Code
Enforcement - Texas
Rockwall City - Code
Enforcement - Texas
Euless City - Code
Enforcement - Texas
Gregg County Health
Department - Texas
City of Deer Park Family Clinic
- Texas
Hedwig Village Health
Department - Texas
Llano County Department of
Natural Resources - Texas
City of Brenham - Texas
Bandera County Permits and
Inspections Courthouse Texas
Seguin City Health
Inspections - Texas
Real County Department of
Sanitation - Texas
City of Big Lake - Texas
Ward County Health Officer Texas
Bee County Health
Department - Texas
Kingsville City-Kleberg County
Health Unit - Texas
Brazoria County Health
Department - Texas
Brazos County Health District
- Texas
Brownwood-Brown County
Health Department - Texas
Calhoun County Health
Department - Texas
Comal County Health
Department - Texas
Cameron County Health
Department - Texas
Cass County Health
Department - Texas
Corpus Christi-Nueces County
Health Department - Texas
127
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Stickney Public Health District Illinois
Tazewell County Health
Department - Illinois
Vermilion County Health
Department - Illinois
Wabash County Health
Department - Illinois
Wayne County Health
Department - Illinois
Whiteside County Health
Department - Illinois
Will County Health Department Illinois
Marion Regional Office/Illinois
Department of Public Health Illinois
Winnebago County Health
Department - Illinois
Woodford County Health
Department - Illinois
Clinton County Health
Department - Illinois
Peoria Regional Office/Illinois
Department of Public Health Illinois
Crawford County Health
Department - Illinois
Rockford Regional Office/Illinois
Department of Public Health Illinois
Edgar County Public Health
Department - Illinois
West Chicago Regional
Office/Illinois Dept. of Public
Health - Illinois
Madison County Health
Department - Illinois
Warren County Health
Department - Illinois
Marion County Health
Department - Illinois
Stark County Health Department
- Illinois
Washington County Health
Department - Illinois
Monroe County Health
Department - Illinois
Moultrie County Health
Department - Illinois
Adams County Health
Department - Indiana
Scott County Health Department
- Illinois
Fort Wayne - Allen County Health
Department - Indiana
Bartholomew County Health
Department - Indiana
Chicago Regional Office/Illinois
Department of Health - Illinois
Benton County Health
Department - Indiana
Stillwater County Health
Department - Columbus
Clinic - Montana
Sweet Grass County Health
Department - Montana
Confederated Salish and
Kootenai Tribal Health Montana
Teton County Health
Department - Montana
Fort Belknap Tribal Health
Department - Montana
Toole County Health
Department - Montana
Fort Peck Tribal Health Montana
Valley County Health
Department - Montana
Northern Cheyenne Tribal
Health Department Montana
Wibaux County Health
Department - Montana
Rocky Boy Tribal Health
Department - Montana
RiverStone Health - Montana
Alamance County Health
Department - North Carolina
Treasure County Health
Department - Montana
Alexander County Health
Department - North Carolina
Blackfeet Tribal Health
Department - Montana
Anson County Health
Department - North Carolina
Appalachian District Health
Department - North Carolina
Beaufort County Health
Department - North Carolina
Bladen County Health
Department - North Carolina
Brunswick County Health
Department - North Carolina
Buncombe County Health
Department - North Carolina
Burke County Health
Department - North Carolina
Public Health Authority of
Cabarrus County - North
Carolina
Caldwell County Health
Department - North Carolina
Carteret County Health
Department - North Carolina
Catawba County Health
Department - North Carolina
Chatham County Public
Health Department - North
Carolina
Cherokee County Health
Department - North Carolina
Chambers County Health
Department - Texas
Corsicana-Navarro County
Public Health Department Texas
Cherokee County Health
Department - Texas
Cuero-Dewitt County Health
Department - Texas
Collin County Health
Department - Texas
Denton County Health
Department - Texas
Ector County Health
Department - Texas
City of El Paso Department of
Public Health - Texas
Fort Bend County Health
Department - Texas
Galveston County Health
District - Texas
Grayson County Health
Department - Texas
Greenville-Hunt County
Health Department - Texas
Hardin County Health
Department - Texas
Irving Public Health and
Environmental Services Texas
Harris County Public Health
and Environmental Services Texas
Hidalgo County Health
Department - Texas
Jackson County Health
Department - Texas
Houston Department of
Health and Human Services Texas
Jasper-Newton County Public
Health District - Texas
Jefferson County Health and
Welfare Department - Texas
Kaufman County Health
Department - Texas
Laredo City Health
Department - Texas
Live Oak County Health
Department - Texas
Lubbock City Health
Department - Texas
Marshall-Harrison County
Health District - Texas
Medina County Health
Department - Texas
Pecos County Health
Department - Texas
Midland County Health
Department - Texas
Plainview-Hale County Health
Department - Texas
128
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
CDC Campus Lookup
5.3 Public Health
Agency Details
Roybal Campus/Atlanta, GA
Century Center/Atlanta, GA
Chamblee Campus/Chamblee, GA
Corporate Square/Atlanta, GA
Lawrenceville
Campus/Lawrenceville, GA
Learning Resource
Center/Atlanta, GA
CDC University Office
Park/Atlanta, GA
CDC Warehouse/Chamblee, GA
CDC Anchorage Quarantine
Station/Alaska
CDC Los Angeles Quarantine
Station/California
CDC San Diego Quarantine
Station/California
CDC San Francisco Quarantine
Station/California
CDC Miami Quarantine
Station/Florida
CDC Honolulu Quarantine
Station/Hawaii
CDC Boston Quarantine
Station/Massachusetts
CDC Detroit Quarantine
Station/Michigan
CDC Minneapolis Quarantine
Station/Minnesota
Supervisor Lookup
7.1 Adding New
Supervisors
9.1 PHAP
*List of supervisors will be
maintained and updated by
hostsites*
Language Lookup
English
Afrikaans
Albanian
Amharic
Arabic (Egyptian)
Aramaic
Armenian
Assamese
Aymara
Azerbaijani
Basque
Belarusian
Bengali
Bislama
Bosnian
Bulgarian
Burmese
Catalan
Cebuano
Cherokee
Mandarin
CDC Newark Quarantine
Station/New Jersey
CDC New York Quarantine
Station/New York
CDC Philadelphia Quarantine
Station/Pennsylvania
CDC San Juan Quarantine
Station/Puerto Rico
CDC Dallas/Ft. Worth
Quarantine Station/Texas
CDC El Paso Quarantine
Station/Texas
CDC Houston Quarantine
Station/Texas
CDC Seattle Quarantine
Station/Washington
CDC Washington Quarantine
Station/Washington D.C.
NIOSH/Anchorage, AK
NIOSH Western States
Office/Lakewood, CO
Hyattsville/Hyattsville, MD
Durham (Offices and
Laboratories)/Research
Triangle Park, NC
Cincinnati, Hamilton Building
(Offices and
Laboratories)/Cincinnati, OH
Cincinnati, Taft Building
(Offices and
Laboratories)/Cincinnati, OH
Spokane/Spokane, WA
Morgantown (Offices and
Laboratories)/Morgantown,
WV
CDC Fort Collins/Colorado
CDC Arctic Investigations
Program/Alaska
Hindi
Hungarian
Icelandic
Irish
Italian
Japanese
Javanese
Kannada
Kazakh
Khmer
Korean
Lao
Latvian
Lithuanian
Macedonian
Malagasy
Malayalam
Marathi
Mongolian
Nahuatl
Navajo
Spanish
Swahili
Swedish
Tagalog
Tajik
Tamil Telugu
Thai
Tibetan
Tok Pisin
Turkish
Turkmen
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Yiddish
Yoruba
Zapotec
Zulu
Uyghur
Yucatec Maya
Arabic (Not Specified)
Chinese (Not Specified)
Creole (Not Specified)
Malay
Other Spoken Language:
129
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
Attachment 5 – FMS Host Site Module
Croatian
Czech
Danish
Dutch
Egyptian
Estonian
Finnish
French
Georgian
German
Greek
Guarani
Gujarati
Creole (Haitian)
Hausa
Hawaiian
Hebrew
Nepali
Norwegian
Oriya
Oromo
Farsi
Polish
Portuguese
Punjabi
Pashto
Romanian
Romany
Russian
Sanskrit
Serbian
Slovak
Slovenian
Somali
Arabic (Levantine)
Arabic (Modern Standard)
Arabic (Moroccan)
Indonesian (Not Specified)
Bahasa Melayu
Balochi
Berber
Cantonese
Dari
Ilokano
Inuit
Kurdi
Kyrgyz
Lakota
Ojibwa
Quechua
Quiche
130
Attachment 5 – FMS Host Site Module
Form Approved
OMB No. 0920-0765
Exp. Date 03/31/2023
131
| File Type | application/pdf |
| File Modified | 2021-06-08 |
| File Created | 2021-06-08 |