MT Public Health Emergency Preparedness Technical Assistance Request

MT Public Health Emergency Preparedness Technical Assistance Request
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Jurisdiction*

What type of Technical Assistance is being requested? (Select all that apply)*

Outreach & CollaborationPlansTrainingExercises (Including This is Test Game)Strategic National Stockpile (CRI jurisdictions only)Hospital Preparedness Program (Including PortaCount)Finance/BudgetInformation ManagementAccess and Functional NeedsVolunteer NeedsOther
Outreach & Collaboration

Identify Community PartnersFacilitate Partner DiscussionOther
Plans

Plan ReviewPlan templateOther
Exercises

Planning (Development of tabletop or full scale exercise)Evaluation (After Action Report/Improvement Plan)This is a Test POD EditionOther
Training

Incident Command CoursesPlan Development and MaintenancePublic Health LawAccess & Functional Needs with Montana Public Health InstituteInformation ManagementOther
Access & Functional Needs

AFN Guide Presentation to Staff/Community PartnersReview/assess existing practices & implement new practicesConnect to AFN subject matter expertsConnect to AFN resourcesFacilitation RequestedOther
Strategic National Stockpile/CHEMPACK

POD SupportDispensing/Distribution PlanningInventory TrackingReceiving/Storing SuppliesCHEMPACKOther
Hospital Preparedness

PortaCount Respirator Fit TesterOther
Information Management

Public Health DirectoryHAN distributionOther
Finance/Budget

Allowable ExpensesOther
Volunteer Needs

Volunteer ManagementVolunteer RequestOther
Plans (Upload the plan(s) to be reviewed)

Cancelof
Do you plan to use This is a Test as an educational and/or teambuilding event? Or do you plan to use This is a Test to exercise your jurisdiction's POD plan?

Educational and/or teambuildingExercise POD plan
This is a Test:
If you plan to use This is a Test to exercise your jurisdictional POD plan please complete the information below.

Number of players anticipated to participate:Number of players*
Exercise Location (Street Address)*         City*   State*   Zip*
Preferred dates of exercise (enter 2-3 date options):   Preferred dates of exercise*
Partners to be included:   Partners to be included*

For jurisdictions using This is a Test to exercise their POD plan onsite facilitation will be offered based on each jurisdiction's needs.
This is a Test:
If you plan to use This is a Test as an educational and/or teambuilding event in your jurisdiction please complete the information below.

Number of game set needed (based on 3-7 players for each set):Number of games*
Shipping Address(Street Address)*      City*   State*   Zip*
Date game is needed by:   Date needed by*
How long do you anticipate needing the game?   Anticipated length

For jurisdictions using This is a Test for educational and/or teambuilding events, the MT PHEP section will ship the game and provide technical assistance prior to the event. No onsite facilitation will be provided.
HPP PoraCount Equipment Loan Program

Please read the FAQs and complete all of the requested information below.
Program FAQ
There is NO cost to use this program.
Organizations may keep the PaC for up to 3 weeks. (Though every effort should be made to minimize the amount of time needed.)
This program is for fit testing the N95 disposable particulate respirator. Other respirators are not supported.
HPP will pay for the shipping to and the return of the PaC from the requesting organization.
Future training on the use of the PaC will be done via pre-recorded videos.
HPP will provide technical support to the requesting organization via phone, email, or teleconference. Site visits should not be necessary.

Please note: This is a loan of the PortaCount (PaC) equipment, accessories, and testing supplies only. The Hospital Preparedness Program (HPP) WILL NOT conduct the fit testing or provide N95 respirators.

Shipping Address Address Line 2 City State Zip
How many personnel do you plan on fit-testing? Number of personnel needing fit-testing
What date will you begin fit-testing?date to begin fit -testing
How many days do you expect/estimate you will be conducting fit-testing? Number of days conducting fit-testing
What kind of volunteer is needed? blanks
Duties volunteer will be performing blank
Pay rate being offered for volunteer blank
Volunteer Work Hours blank
Lodging provided for volunteer blank
Per diem provided for volunteer blank
Milage reimbursement provided for volunteer blank
Can the requesting jurisdiction pay for this request? blank
Point of Contact for requesting jurisdiction name, phone number and email
Additional information regarding the request
Should be Empty: