Unit Profile

Medical Reserve Corps (MARC) Unit Profile and Reports

0990-0302 1_Unit Profile

Unit Profile

OMB: 0990-0302

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Unit Profile

Collection Tool

Form Approved

OMB No. 0990-0302

Exp. Date XX/XX/20XX



Element

Data Element

Collection Tool


Sub Factor 1.1 Determine Jurisdiction Served

Jurisdiction Type: Mixed, Rural/Frontier, Suburban, Tribal, Urban

Unit Profile Data Elements


Sub Factor 1.1 Determine Jurisdiction Served

Coverage Type: City/Town, County

Unit Profile Data Elements


Sub Factor 1.1 Determine Jurisdiction Served

Select Jurisdiction: Add State, Select County or Zip Code, Add Selected County or Zip Codes

Unit Profile Data Elements


Sub Factor 1.1 Determine Jurisdiction Served

Jurisdiction Notes: Free Text Box

Unit Profile Data Elements


Sub Factor 1.3 Develop Mission Statement

Unit Mission Statement: Free Te

xt Box

Unit Profile Data Elements


Sub Factor 1.4 Determine Goals and ‘SMART’ Objectives

Unit Goals/Objectives: Free Text Box

Unit Profile Data Elements


Sub Factor 2.1 Develop Working Partnerships and Affiliations with Organizations in the Community


Partner Organization –Drop Down List


Health Department

Board of Health

Emergency Management Agency

Citizen Corps Council

Volunteer Center

Hospital/Health System

Non-Governmental Organizational

Medical/Professional Society

Civic Organization

Fire Department/Fire Protection District

Law Enforcement/Agency

EMS Agency

Regional Planning Council/Commission

Other

College/University

Other Local Governmental Agency/Department

American Red Cross Chapter

Faith-Based Organization

Private Sector –Business/Corporation

State Governmental Agency/Department

Urban Area Security Initiatives

Cities Readiness Initiative (CRI)

Strategic National Stockpile (SNS)

National Disaster Medical System (NDMS)

HOSA-Future Health Professionals

AmeriCorps/VISTA/Senior Corps

Animal Health/Veterinary Agency or Organization

County/State Animal Response Teams (CART/SART)

High School

Military Unit/Organization

Tribal Organization/Agency

Community Health Center

Unit Profile Data Elements

New

Sub Factor 2.1 Develop Working Partnerships and Affiliations with Organizations in Community

“Is your MRC unit included in your jurisdiction’s Emergency Operations Plan(s)?”

Unit Profile Data Elements


Sub Factor 3.2 Identify and Pursue Funding and/or Resources


Funding Sources:


In-kind from sponsor organization

In-kind from partner organization

Financial contributions/grants from private sector (business and industry)

Financial contributions/grants from foundations and other non-governmental organizations

Financial contributions/grants from local governmental agencies

Financial contributions/grants from state governmental agencies

Financial contributions/grants from federal governmental agencies

Unit Profile Data Element


Sub Factor 4.1 Identify and Appoint MRC Leadership

User Demographics: Name, Title, Organization, Address 1, Address 2, Phone, Fax, Email Address, Leader Type (Employee/Volunteer), Number of Hours per Week focus on MRC

User Profile Data Elements


Sub Factor 4.4 Determine Unit Composition

Number of Volunteers:

Acupuncturist

Chaplain/Clergy

Clinical Social Worker

Dentists

EMS Professionals

Licensed Practical Nurse/Licensed Vocational Nurse

Mental Health Counselor/Therapist

Non-Public Health/Non-Medical

Nurse Practitioner

Other Public Health/Medical

Pharmacist

Physician

Physician Assistant

Psychiatrist

Psychologist

Registered Nurse

Respiratory Therapist

Veterinarian

Veterinarian Technician

Unit Profile Data Elements


Sub Factor 4.4 Determine Unit Composition

Are your MRC members included, or do you plan to include them in the State Volunteer Registry (ESAR-VHP)? (Yes/No selection)

Unit Profile Data Element


Sub Factor 4.4 Determine Unit Composition

Does your MRC unit allow youth membership (under 18 years of age)? (Yes/No selection)

Unit Profile Data Element

New

Sub Factor 6.1 Screen and Select Volunteer for MRC Membership

To What Level are your unit’s MRC volunteers credentialed by either the local unit or the state? (Drop Down List Selection) with definition

Level 1: Identified volunteers who are clinically active in a hospital, either an employee or by having hospital privileges


Level 2: Identifies volunteers who are clinically active in a wide variety of settings, such as clinics, nursing homes and shelters


Level 3: Identified volunteers who meet the basic qualifications necessary to practice in the state in which they are registered


Level 4: Identified volunteers who have experience or education that would be useful not controlled by scope of practice laws (may include health professions students or retired health professionals who no longer hold a license


Level 5: Do not verify credentials

Unit Profile Data Element


Sub Factor 6.1 Screen and Select Volunteer for MRC Membership

Does your MRC unit require “Fit-for-duty” checks (i.e. physical and mental)? (Yes/No selection)

Unit Profile Data Element


Sub Factor 7.1 Develop a Training Plan

Does your MRC unit utilize the MRC Core Competencies? (Yes/No selection)

Unit Profile Data Element


Sub Factor 7.1 Develop a Training Plan

Does your MRC unit utilize MRC-TRAIN or your state affiliated TRAIN? (Yes/No selection)

Unit Profile Data Element


Sub Factor 7.1 Develop a Training Plan

Is your MRC unit compliant or working toward compliance with NIMS requirements? (Yes/No selection)

Unit Profile Data Element


Sub Factor 7.1 Develop a Training Plan

Does your MRC unit participate in training exercises/drills with local partners? (Yes/No selection)

Unit Profile Data Element

New

Sub Factor 7.1 Develop a Training Plan

Which of the following competency areas does your unit have required training? (Select all that apply)


Personal and family preparedness for disasters and public health emergencies


Knowledge of personal safety measures that can be implemented in a disaster or public health emergency


Knowledge of one’s expected role(s) in organizational and community response plans activated during a disaster or public health emergency


Communicate effectively with others in a disaster or public health emergency


Knowledge of surge capacity assets consistent with one’s role in organizational, agency, and/or community response plans


Knowledge of principles and practices for the clinical management of all ages and populations affected by disasters and public health emergencies, in accordance with professional scope of practice


Situational awareness of actual/potential health hazards before, during and after a disaster or public health emergency


Knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies


Knowledge of ethical principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency


Knowledge of legal principles to protect the health and safety of all ages, populations and communities affected by a disaster or public health emergency


Knowledge of short- and long-term considerations for recovery of all ages, populations, and communities affected by a disaster or public health emergency

Unit Profile Data Element


Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers


Do you track your MRC member’s willingness to deploy outside of the local jurisdiction? (Yes/No)

Unit Profile

Data Element

New

Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers


Does your unit have mobilization plan?

Unit Profile Data Element

New

Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers


Does your unit have a demobilization plan?

Unit Profile Data Element


Sub Factor 11.2 Determine Volunteer legal Protections


Legal Protections Row Headers

Liability/Malpractice

Workers Compensation

Re-employment Rights

No Legal Protections


Legal Protections Column Headers

During declared emergencies

During Non-Emergency/Public Health Event

During Training Activities

All MRC Related Activities

Unit Profile

Data Element


Sub Factor 11.2 Determine Volunteer Legal Protections

(Click all that apply)

Source of Legal Protections in Place

Local Agency

County legislation/regulation

State Agency

State Good Samaritan Laws

State Legislation specifically protecting volunteer health professionals

Purchased private insurance

Federal Volunteer Protection Act

Workers Compensation

Other (please specify)

Unit Profile

Data Element


Describe the Jurisdiction that your MRC unit will cover?


New Unit Interview Question


Describe the public health and emergency preparedness/response mission and focus of your mrc unit?

New Unit Interview Question


Describe the goals and objectives of your MRC unit?

New Unit Interview Question


Describe your MRC unit’s affiliations and partnerships with other local or state governmental or non-governmental organizations and agencies?

New Unit Interview Question


Describe how your MRC unit is integrated with the local and state emergency plans (ESF-8) for your jurisdiction?

New Unit Interview Question


Describe the organization structure of your MRC unit?

New Unit Interview Question


Describe the composition of your MRC unit?

New Unit Interview Question


Describe the recruitment plans of your unit?

New Unit Interview Question


Describe your MRC unit’s plans for screening and selecting members and staff, including the verification of professional credentials?

New Unit Interview Question


Describe your MRC unit’s administrative plans and procedures?

New Unit Interview Question


Describe how your MRC unit has participated in the MRC “network”?

New Unit Interview Question

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0302. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHager, Katie (OS/ASPR/EMMO)
File Modified0000-00-00
File Created2022-06-01

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