NWRHCC Training, Exercise, & Document Support Request Form
A minimum of four weeks notice is required for any training or exercise planning and assistance, plan reviews, and assistance with policy and procedure development. Both the Readiness and Response Coordinator and Clinical Advisor will review and sign off on the completed work prior to you receiving your completed documents.
Organization Requesting Assistance
Organization Name
Point of Contact
First Name
Last Name
Point of Contact Title or Role
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Request
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Assistance Requested
Please select the type of assistance you are requesting and provide as much detail as possible. Options include Training, Exercises or Drills, Plan Review, Policy and Procedure Review or Development.
Training Assistance
What type of training is needed?
Who is the target audience? (e.g., staff, leadership, clinical, non-clinical)
Preferred method of training delivery?
In Person
Virtual
Hybrid
Other
What clinical components would you like to be included or tested?
Patient surge capacity
Triage and prioritization
Mass casualty incident response
Pediatric emergency response
Burn care and trauma response
Isolation and quarantine procedures
Infectious disease outbreak management
Bioterrorism or emerging pathogens
Hazmat exposure response
Decontamination (hospital and pre hospital)
Radiation exposure and containment
Chemical spill response
Long term care facility transfer plans
Neonatal and pediatric disaster response
Morgue and mass fatality management
Coordination with EMS and transport services
Other
Are you seeking the NWRHCC to facilitate the training, or only help with planning/preparation?
Planning and preparations
Facilitate
Other
What is your deadline to have the requested information?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exercise and Drill Assistance
What type of exercise/drill is needed?
Tabletop
Functional
Full Scale
Other
What specific capabilities or areas do you want to test?
What clinical components would you like to be included or tested?
Patient surge capacity
Triage and prioritization
Mass casualty incident response
Pediatric emergency response
Burn care and trauma response
Isolation and quarantine procedures
Infectious disease outbreak management
Bioterrorism or emerging pathogens
Hazmat exposure response
Decontamination (hospital and pre hospital)
Radiation exposure and containment
Chemical spill response
Long term care facility transfer plans
Neonatal and pediatric disaster response
Morgue and mass fatality management
Coordination with EMS and transport services
Other
What specific scenarios or hazards do you want to include?
Who will be participating in the exercise (e.g., internal departments, community partners, external agencies, leadership)
Are you seeking the NWRHCC to facilitate the training, or only help with planning/preparation?
Planning and preparations
Facilitate
Other
Please provide any additional details.
What is your deadline to have the requested information?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Organization Plan Review Assistance
What specific plan(s) do you need assistance with reviewing?
Emergency Operations Plan
COOP
Pandemic Response
Other
Please provide a detailed description of what you are looking for.
What is your deadline to have the requested information?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy and procedure development or review assistance
What specific policy or procedure are you seeking assistance with?
Are there any regulatory or compliance requirements to consider (e.g., DNV, Joint Commission, CMS, State)
What are your key concerns or areas of focus?
Please provide any additional details.
What is your deadline to have the requested information?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please provide any files or documents here.
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