ࡱ> '` bjbjLULU ;.?.?,%   "     8dHF$$"I"DIDIDIDI^ RVW\AAAAAAA$2JhLBE YDIDIYYB  DIDILHYn  DI DIAYAd  oDI:$ 1^]\ zn 3"PbH0HU$Mn $MDoor$M YYYYYYYBBYYYHYYYYY&  .       CRI MSA Affiliate:  FORMTEXT       Assessment Date:  FORMTEXT       County/Project Area/Planning Jurisdiction:  FORMTEXT       Reviewer:  FORMTEXT       Baseline Data for ReviewResponse1Local population covered by local planning jurisdictions medical countermeasure dispensing plan. HYPERLINK "file:///C:\\Documents%20and%20Settings\\hft6\\Local%20Settings\\Temporary%20Internet%20Files\\Content.Outlook\\WRWUMCYF\\Local%20Technical%20Assistance%20Review%20(Proposed%202010%20ext)_(2).docx" \o "The most current US Census population and citation that reflects the population covered by the jurisdictional SNS Plan."TIP FORMTEXT      Notes: FORMTEXT      2Hourly throughput needed to provide prophylaxis to 100% of the population within 48 hours of decision to deploy SNS. HYPERLINK \l "Tip_2" \o "Throughput should be defined as the number of persons visiting the POD (i.e.prophylaxed) per hour. Depending on the PODs in your jurisdiction, estimates can be submitted in several ways. See Page 27 for additional information."TIP FORMTEXT      AEstimate of hours available for operations to meet the 48 hour goal for dispensing after receipt of assets from state/local distribution.  FORMTEXT      3Total number of Points of Dispensing (PODs) identified to cover 100% of the planning jurisdiction population. HYPERLINK \l "Tip_3" \o "Total PODs (traditional) that have been identified to serve 100% of the population identified in #1."TIP  FORMTEXT      Notes: FORMTEXT      4Calculated total estimated hourly operational throughput, based on modeling, exercise or estimate, to provide prophylaxis to 100% of the jurisdictions population within 48 hours through operation of all PODs identified in 3. HYPERLINK \l "Tip_2" \o "Throughput should be defined as the number of persons visiting the POD (i.e.prophylaxed) per hour. Depending on the PODs in your jurisdiction, estimates can be submitted in several ways. See Page 27 for additional information."TIP FORMTEXT      Notes:Was Head of Household used in this calculation?  FORMTEXT       What number of multiple regimens is authorized?  FORMTEXT       Additional comment:  FORMTEXT      5Number of PODs (general population) identified and supported through written agreement. HYPERLINK \l "Tip_4" \o "Number of PODs with established MOA's, MOUs or other written agreements in place to support use during public health emergency."TIP  FORMTEXT      Notes: FORMTEXT      6.Number of PODs (general population) with documented site-specific plans. HYPERLINK \l "Tip_5" \o "Number of PODs with completed site specific operational plans. Number of PODs with in-progress or incomplete plans should be placed under NOTES section."TIP FORMTEXT      Notes: FORMTEXT      7.Number of POD (general population) with identified primary and back-up management teams. HYPERLINK \l "Tip_6" \o "Number of PODs with primary and back-up management staff identified and rostered."TIP FORMTEXT      Notes: FORMTEXT      8.Estimated number of local government personnel and volunteer staff needed to staff 100% of POD functions for a medical countermeasure distribution and dispensing campaign. HYPERLINK \l "Tip_8" \o "Estimated number of personnel needed to staff all POD operational functions. This number will be a total number of local PH staff and volunteers needed to support all PODs. "TIP FORMTEXT      Notes: FORMTEXT      9.Current number of local government personnel volunteer staff identified to staff POD functions for a mass prophylaxis campaign and/or medical supplies management and distribution. HYPERLINK \l "Tip_8" \o "Number of personnel currently available through PH or volunteer databases to staff operations and security at all PODs. "TIP FORMTEXT      Notes: FORMTEXT       10.Lines 10a-h relates to specific types of alternate dispensing modalities present in the project area. ANumber of drive-though PODs  FORMTEXT      BNumber of Closed PODs with healthcare entities/agencies (e.g., nursing homes, long term care facilities, skilled nursing facilities, retirement homes, hospitals, etc.) FORMTEXT      CNumber of Closed PODs with private business (e.g., local chemical/power plant, grocery stores, newspapers, banks, hardware stores, car companies, etc.) FORMTEXT      DNumber of Closed PODs with governmental agencies (e.g., DHS components, HHS operating divisions, VA Hospitals, local IRS offices, jails, juvenile detention programs, county/city departments, tribal, etc.) FORMTEXT      ENumber of Closed PODs with military installations e.g., active duty bases, National Guard units) FORMTEXT      FNumber of Closed PODs with academic institutions (e.g., universities, colleges, high schools, school districts, elementary schools, etc.) FORMTEXT      GNumber of Closed PODs with community-based agencies (e.g., Meals on Wheels, agencies assisting homeless, American Red Cross, United Way, VOAD, etc.) FORMTEXT      HNumber of PODS using other types of alternate dispensing modalities (please explain in Notes section below) Notes: FORMTEXT      11.Population covered by all Closed POD alternate dispensing modalities. (9b-h above) HYPERLINK \l "Tip_91" \o "Total population to receive prophylaxis at Closed POD locations identified in 9b-h. Clarification or additional detail can be placed in Notes section.."TIPNotes: FORMTEXT       SECTION ONE: DEVELOPING A PLAN WITH SNS ELEMENTS (3%)1.1Local SNS planning elements are incorporated in the local all-hazards plan and are NIMS-compliant.  FORMCHECKBOX 1Local SNS planning elements are incorporated into the local all-hazards plan and are NIMS-compliant. FORMCHECKBOX 0Local SNS planning elements are not incorporated into the local all-hazards plan and are not NIMS-compliant.NOTES: FORMTEXT       1.2Local SNS planning elements are updated annually based on deficiencies revealed during federal and/or state SNS Program Technical Assistance Reviews and state/local trainings and exercises. FORMCHECKBOX 1Planners have documentation that the local SNS planning elements included in the all-hazards plan are updated annually.  FORMCHECKBOX 0Planners do not have documentation and/or the local SNS planning elements included in the all-hazards plan are not updated annually.NOTES: FORMTEXT       1.3Multi-discipline planning/advisory group or partners meet annually to review and/or update the SNS planning elements in the all-hazards plan. FORMCHECKBOX  Health Department FORMCHECKBOX  Department of Administrative/Finance FORMCHECKBOX  Organizations Servicing At-Risk Pop. FORMCHECKBOX  Mental Health/Crisis Professionals FORMCHECKBOX  Department of Corrections FORMCHECKBOX  Private Business Representatives FORMCHECKBOX  Emergency Management Agency FORMCHECKBOX  Military Installations FORMCHECKBOX  Volunteer Organizations FORMCHECKBOX  State Office of Homeland Security FORMCHECKBOX  Tribal Nations FORMCHECKBOX  Civic Organizations FORMCHECKBOX  Public Works FORMCHECKBOX  Regional HHS Liaison(s) FORMCHECKBOX  Professional Organizations FORMCHECKBOX  Department of Transportation FORMCHECKBOX  MMRS Representative FORMCHECKBOX  Other  FORMCHECKBOX  Law Enforcement FORMCHECKBOX  NDMS Representative FORMCHECKBOX  Hospitals/Alternate Care Facilities FORMCHECKBOX  Medical Reserve Corps FORMCHECKBOX  Emergency Medical Services FORMCHECKBOX  Community Emergency Response Team FORMCHECKBOX  Fire FORMCHECKBOX  Home Health/Visiting Nurse FORMCHECKBOX 1The planning/advisory group includes representatives of 50% or more of the applicable agencies and institutions listed above and meeting documentation is available for review.  FORMCHECKBOX 0.5The planning/advisory group includes less than 50% of representatives from the applicable agencies and institutions listed above and meeting documentation is available for review.  FORMCHECKBOX 0A planning group has not been formed or meeting documentation is not available for review.NOTES: FORMTEXT       1.4The roles and responsibilities of local agencies and/or other organizations concerning SNS planning elements are documented. FORMCHECKBOX 1Local planners have supporting documentation indicating appropriate local agencies and/or other organizations acknowledge their roles and responsibilities concerning the SNS planning elements indicated in the local all-hazards plan.  FORMCHECKBOX 0Local planners have no verifiable documentation that local agencies and/or other organizations have acknowledged their roles/responsibilities in SNS planning elements.NOTES: FORMTEXT       1.5State and local policies and procedures to support local mass prophylaxis operations and/or medical supplies management and distribution are referenced in plan, including: FORMCHECKBOX  Process for requesting SNS assistance FORMCHECKBOX  Policy for dispensing multiple regimens to family members and household at a dispensing site FORMCHECKBOX  Policy for dispensing to unaccompanied minor FORMCHECKBOX  Policy for minimum identification requirements in order to receive medication FORMCHECKBOX  Policy for use of force by law enforcement FORMCHECKBOX  Policy for providing prophylaxis to tribal nations (if applicable) FORMCHECKBOX  Procedure for providing support to prophylaxis to military installation(s) within jurisdiction (if applicable) FORMCHECKBOX 1All the applicable policy issues listed above have been reviewed, identified, and incorporated in the SNS planning efforts to support mass prophylaxis operations and/or medical supplies management and distribution. FORMCHECKBOX 0All the applicable policy issues listed above have not been incorporated in the SNS planning efforts to support mass prophylaxis operations and/or medical supplies management and distribution.NOTES: FORMTEXT       1.6Legal issues to support medical countermeasure distribution and dispensing are outlined in plan, including: FORMCHECKBOX  Medical practitioners authorized to issue standing orders and protocols for dispensing sites FORMCHECKBOX  Personnel authorized to dispense medications during a state of emergency FORMCHECKBOX  Procurement of private property FORMCHECKBOX  Liability protection FORMCHECKBOX  Workers compensation FORMCHECKBOX  Staff compensation FORMCHECKBOX 1All of the legal issues listed above have been identified, outlined or referenced in the plan. FORMCHECKBOX 0All of the legal issues listed above have not been identified, outlined or referenced in the plan.NOTES: FORMTEXT      SECTION ONE: Points  FORMTEXT       Divided by 6 =  FORMTEXT       SECTION TWO: MANAGEMENT OF SNS (10%)2.1Local SNS Coordinator identified with back-up and POC information. FORMCHECKBOX 1The local SNS Coordinator and back-up have been identified and their emergency contact information is available. FORMCHECKBOX 0.5Only the local SNS Coordinator has been identified or POC information is not provided for person(s) identified. FORMCHECKBOX 0Local SNS Coordinator and back-up have not been identified.NOTES: FORMTEXT       2.2Personnel (Lead and back-up) have been identified at the local level to oversee the planning and management of the following functional area and contact information is documented. FORMCHECKBOX  Staffing/Volunteer Coordination FORMCHECKBOX  Dispensing Site operations FORMCHECKBOX  Tactical Communications/IT Support FORMCHECKBOX  Inventory Management FORMCHECKBOX  Security Coordination FORMCHECKBOX  Hospital/Alternate Care Facilities coordination FORMCHECKBOX  RDS Operations, if applicable FORMCHECKBOX  Public Information and Communication FORMCHECKBOX  Distribution operations, if applicable FORMCHECKBOX  Safety Coordination FORMCHECKBOX 1Lead / management staff has been identified for all functional planning areas listed above and contact information is documented. FORMCHECKBOX 0.5Six or more of the lead and back-up staff have been identified and contact information documented. FORMCHECKBOX 0Less than six of the lead and back-up staff have been identified and contact information documented.NOTES: FORMTEXT       2.3Call-down lists for personnel identified in item 2.2 are current and updated quarterly. FORMCHECKBOX 1Call-down lists exist for all listed above and are updated quarterly. FORMCHECKBOX 0.5Call-down lists exist for all listed above and are updated less than quarterly. FORMCHECKBOX 0Call-down lists have not been developed or are not available for review.NOTES: FORMTEXT       2.4Local jurisdiction conducts and documents call-down exercises of all personnel identified in item 2.2 at least quarterly FORMCHECKBOX 1Call-down exercises are conducted quarterly, the results of these drills are documented, and any identified discrepancies corrected and documented. FORMCHECKBOX 0.5Call-down exercises are conducted less than quarterly. FORMCHECKBOX 0No documentation exists that quarterly call-down exercises were conducted.NOTES: FORMTEXT       2.5SNS functions have been incorporated under the applicable functional area of the jurisdiction s Incident Command Structure and are documents.  FORMCHECKBOX  Staffing/Volunteer Coordination FORMCHECKBOX  Inventory management FORMCHECKBOX  Tactical Communications/IT Support FORMCHECKBOX  Dispensing Site operations FORMCHECKBOX  SNS Security Coordination FORMCHECKBOX  Hospital/Alternate Care Facilities Coordination FORMCHECKBOX  RDS Operations, if applicable FORMCHECKBOX  Public Information and Communication FORMCHECKBOX  Distribution Operations, if applicable FORMCHECKBOX  Safety Coordination FORMCHECKBOX 1All of the above SNS functions are incorporated under the applicable functional area of the jurisdictions ICS organizational chart. FORMCHECKBOX 0.5Six or more of the above SNS functions are incorporated under the applicable functional area of the jurisdictions ICS organizational chart. FORMCHECKBOX 0Less than six of the above SNS functions are incorporated under the applicable functional area of the jurisdictions ICS organizational chart. NOTES: FORMTEXT       2.6The local jurisdiction annually exercises the notification and activation process for all personnel below the local level management positions identified in item 2.2. FORMCHECKBOX 1The local jurisdiction has a plan, tests or exercises the plan annually, and has a corrective action plan to address identified discrepancies.  FORMCHECKBOX 0.5The local jurisdiction has a plan in place but the plan has tested/exercised the plan on a less than annual basis and/or corrective actions plans are not in place. FORMCHECKBOX 0A plan does not exist.NOTES: FORMTEXT      SECTION TWO: Points  FORMTEXT       Divided by 6 =  FORMTEXT       SECTION THREE: REQUESTING SNS (3%)3.1Plan to communicate with key local officials to discuss incident to determine the need to request state assistance. FORMCHECKBOX 1Local health officials have a written plan to communicate with the key local leaders regarding the decision to request state assistance. FORMCHECKBOX 0Local health officials do not have a written plan to communicate with the key local leaders regarding the decision to request state assistance.NOTES: FORMTEXT       3.2Personnel authorized by the local health director to request state assistance are identified in the plan with contact information. FORMCHECKBOX 1Personnel authorized to request are documented in the local all-hazards plan with contact information. FORMCHECKBOX 0Personnel authorized to request are not documented in the local all-hazards plan.NOTES: FORMTEXT       3.3Plan details initial request justification guidelines and procedures for locals to request medical countermeasure distribution and dispensing assistance from the state. FORMCHECKBOX 1Plan details justification guidelines and procedures for requesting state assistance. FORMCHECKBOX 0Plan does not details justification guidelines and procedures for requesting state assistance.NOTES: FORMTEXT       3.4Plan contains procedures for re-supply of medical countermeasures and material from the state. FORMCHECKBOX 1Plan describes procedures for requesting re-supply from the state. FORMCHECKBOX 0Plan does not describe procedures for requesting re-supply from the state.NOTES: FORMTEXT       3.5Plans contain procedures for dispensing sites to request re-supply through their jurisdiction s incident command. FORMCHECKBOX 1Plan describes procedures for dispensing sites to request re-supply through their incident command. FORMCHECKBOX 0Plan does not describe procedures for dispensing sites to request re-supply through their incident command.NOTES: FORMTEXT      SECTION THREE: Points  FORMTEXT       Divided by 5 =  FORMTEXT       SECTION FOUR: COMMUNICATIONS PLAN (TACTICAL) (3%)4.1Tactical communication and/or IT support staff call down lists in support communications pathway operations identified in 4.4 are reviewed and updated quarterly. FORMCHECKBOX 1Documentation supports process where communication/IT support call-down lists that are reviewed and updated quarterly  FORMCHECKBOX 0No documentation substantiates that communication/IT support call down lists are reviewed and updated quarterly.NOTES: FORMTEXT       4.2Job Action Guides exist for Communications/IT support personnel. FORMCHECKBOX 1A job action guide is included in the plan for communication/IT support personnel. FORMCHECKBOX 0A job action guide has not been developed.NOTES: FORMTEXT       4.3Redundant communications platforms and systems are in place and are tested quarterly to ensure communications remain available in the event primary communication systems are unavailable. FORMCHECKBOX  Landline dependent telecommunications; landline telephones, FAX, Dial-up/DSL internet and email FORMCHECKBOX  Amateur (HAM) Radio FORMCHECKBOX  Non-telephone based internet, email and web-based communications access systems; Satellite or Cable  FORMCHECKBOX  Two-Way VHF/UHF/700/800/900 MHz Communications FORMCHECKBOX  Cellular technologies and communications; phone, text  FORMCHECKBOX  Satellite telephone communications FORMCHECKBOX  Government Emergency Telecommunications Service GETS FORMCHECKBOX 1The local jurisdiction has documentation that six or more of the communication platforms or system categories listed above are available to link management/command locations and support agencies and those systems are used routinely or tested quarterly. FORMCHECKBOX 0.5The state has documentation that at four to five of the communication platforms or system categories listed above is available to link management and command locations and support agencies and those systems are used routinely or tested quarterly. FORMCHECKBOX 0The state has three or less of the above listed communication platforms or system categories.NOTES: FORMTEXT       4.4Communication pathways are established between command and management locations and support agencies, where applicable: FORMCHECKBOX  Local EOC(s) FORMCHECKBOX  RDS Locations FORMCHECKBOX  Local Health Department(s) FORMCHECKBOX  Security FORMCHECKBOX  State and/or Regional EOC FORMCHECKBOX  Transportation Resources FORMCHECKBOX  Dispensing Sites FORMCHECKBOX  Regional Distribution (if applicable) FORMCHECKBOX  Hospitals/Alternate Care Facilities FORMCHECKBOX 1The plan contains documentation (e.g. matrix/flow-chart) that delineates communication pathways and support devices supporting the all applicable command and management locations listed above. FORMCHECKBOX 0.5The plan contains documentation (e.g. matrix/flow-chart) that delineates communications pathways but does not identify the communication device(s) supporting each pathway. FORMCHECKBOX 0The plan does not contain documentation delineating communication pathways between command and management locationsNOTES: FORMTEXT       4.5Communication networks (equipment/hardware) between command and management locations and support agencies are tested quarterly. FORMCHECKBOX 1The local jurisdiction provides supporting documentation that communication networks are tested quarterly and corrective action plans have been developed to address identified deficiencies. FORMCHECKBOX 0.5The local jurisdiction provides supporting documentation that communication networks have been tested less than quarterly. FORMCHECKBOX 0The local jurisdiction is unable to provide supporting documentation that communication networks have been tested less than quarterly.NOTES: FORMTEXT       4.6Designated personnel (identified in item 2.2) are trained in the use of redundant communications equipment. FORMCHECKBOX 1The local jurisdiction can provide documentation to support that designated personnel have been trained.  FORMCHECKBOX 0The local jurisdiction is unable to document that designated personnel have been trained.NOTES: FORMTEXT      SECTION FOUR: Points  FORMTEXT       Divided by 6 =  FORMTEXT       SECTION FIVE: PUBLIC INFORMATION AND COMMUNICATION (PIC) (7%)5.1Local public information and communication personnel (identified in 2.2) have been trained on responsibilities associated with a medical countermeasure distribution and dispensing campaign.  FORMCHECKBOX  Training of PIC personnel is documented  FORMCHECKBOX  Job action guides have been developed and approved for use FORMCHECKBOX 1Both of the above are completed and documented.  FORMCHECKBOX 0.5One of the above is completed and documented. FORMCHECKBOX 0None of the above has been completed or documented.NOTES: FORMTEXT       5.2A written PIC plan is developed to support to a medical countermeasure distribution and dispensing campaign and:  FORMCHECKBOX  Is part of the all-hazards public information plan  FORMCHECKBOX  Addresses coordination between local jurisdictions as well as with state to ensure message consistency  FORMCHECKBOX  Identifies a media policy for all distribution and dispensing sites  FORMCHECKBOX  Includes process for establishing hotline/call-bank procedures or other mechanisms to address questions/concerns from the public FORMCHECKBOX 1All four of the components regarding a mass prophylaxis campaign mentioned above are included in the comprehensive written PIC plan. FORMCHECKBOX 0.5Two or three of the components regarding a mass prophylaxis campaign mentioned above are included in the comprehensive written PIC plan. FORMCHECKBOX 0Less than two of the components are present in the comprehensive written PIC plan.NOTES: FORMTEXT       5.3The following PIC responsibilities appear on the job action guide of the PIC liaison or other designated site staff:  FORMCHECKBOX  Coordinate information with the lead PIO and/or JIC  FORMCHECKBOX  Serve as a point of contact for the media  FORMCHECKBOX  Handle public information messages, methods and materials  FORMCHECKBOX 1All three of the components above are included in site plans. FORMCHECKBOX 0.5One to two of the components above are included in site plans. FORMCHECKBOX 0None of the above is included in site plans.NOTES: FORMTEXT       5.4 Messages that are consistent with state and federal guidance have been developed to support medical countermeasure distribution and dispensing at the local level and including messages to: FORMCHECKBOX  Prepare the public before an event FORMCHECKBOX  Help people navigate the dispensing sites FORMCHECKBOX  Direct people to the dispensing sites FORMCHECKBOX  Provide information to people once they leave the dispensing sites FORMCHECKBOX  Inform people about alternate dispensing methods FORMCHECKBOX  Ensure medication compliance FORMCHECKBOX 1Messages for a medical countermeasure distribution and dispensing campaign have been developed, completed, documented, and verified for all of the above. FORMCHECKBOX 0.5Messages for a medical countermeasure distribution and dispensing campaign have been developed, completed, documented, and verified for three to five of the above. FORMCHECKBOX 0Messages for a medical countermeasure distribution and dispensing campaign have been developed, completed, documented, and verified for two or less of the above.NOTES: FORMTEXT       5.5Methods to disseminate the messages indicated in item 5.4 above have been developed, including:  FORMCHECKBOX  Methods of communicating information that get people to the dispensing sites  FORMCHECKBOX  Methods of communicating information that get people through the dispensing sites  FORMCHECKBOX  Alternate methods to disseminate messages in case of electrical outages  FORMCHECKBOX  Development of pre-incident media relationships FORMCHECKBOX 1Methods for disseminating messages during a medical countermeasure distribution and dispensing campaign have been developed, for all of the above. FORMCHECKBOX 0.5Methods for disseminating messages during a medical countermeasure distribution and dispensing campaign have been developed, for at least two of the above. FORMCHECKBOX 0Methods for disseminating messages during a medical countermeasure distribution and dispensing campaign have been developed, completed, documented, and verified for less than two of the above.NOTES: FORMTEXT       5.6Materials (fact sheets, press releases, signs) or templates, consistent with state and federal guidance have been developed and cleared for use: FORMCHECKBOX  To direct people to the dispensing sites FORMCHECKBOX  To provide information to people after they leave the dispensing site FORMCHECKBOX  To help people navigate the dispensing sites FORMCHECKBOX  On medications used for prophylaxis and treatment FORMCHECKBOX  On category A agents and critical public health threats  FORMCHECKBOX  A plan for mass reproduction and storage of printed materials FORMCHECKBOX 1All of the above are developed and available for review. FORMCHECKBOX 0.5Three to five of the above are developed and available for review. FORMCHECKBOX 0Two or less of the above are developed and available for review.NOTES: FORMTEXT       5.7Local plans for information needs of at-risk populations include:  FORMCHECKBOX  Methods of communication to get people to and through dispensing sites  FORMCHECKBOX  Definition and identification of at-risk population groups  FORMCHECKBOX  Development of alternate methods for disseminating information to at-risk populations  FORMCHECKBOX  Development of materials that are easy to read and have been translated to top languages in the community  FORMCHECKBOX  A mechanism to translate information for non-English speaking, hearing impaired, visually impaired, or functionally illiterate individuals FORMCHECKBOX 1All of the above are completed, documented, and verified. FORMCHECKBOX 0.5Three to four of the above are completed, documented, and verified. FORMCHECKBOX 0Two or less of the above are documented and verified.NOTES: FORMTEXT      SECTION FIVE: Points  FORMTEXT       Divided by 7 =  FORMTEXT       SECTION SIX: SECURITY (10%)6.1 FORMCHECKBOX  Local level position (identified in 2.2) that coordinates the overall security issues has been trained on the specific security requirements for medical supplies management and distribution operations. FORMCHECKBOX  Local security support agencies identified and oriented FORMCHECKBOX  Contact information is available for security support agencies FORMCHECKBOX 1The primary and back-up have been trained, contact information documented, and support agencies have been identified. FORMCHECKBOX 0.5The primary and back-up have not been trained, contact information documented, but support agencies have not been identified. FORMCHECKBOX 0The local jurisdiction has not identified a security coordinator or identified security-support agencies.NOTES: FORMTEXT       6.2Security plans for transportation of medical materiel have been developed.  FORMCHECKBOX  Escort plans for materials coming from the RSS (if applicable)  FORMCHECKBOX  Escort plans for materials leaving the Regional Distribution Site (if applicable)  FORMCHECKBOX  Escort plans for transport of materials from dispensing sites to other sites that may need materiel  FORMCHECKBOX  Escort of personnel to and from site venues FORMCHECKBOX 1Applicable security escort plans have been addressed and documented. FORMCHECKBOX 0Security escort plans have not been addressed and documented.NOTES: FORMTEXT       6.3Security Plans have been developed for dispensing site(s) and/or Regional Distribution Site(s) (if applicable) and include:1. Security and vulnerability assessment of location and facility strengths/weaknesses2. Interior physical security of location FORMCHECKBOX  Security sweep prior to facility use/occupancy by staff or product FORMCHECKBOX  Establishment of law enforcement officer posts FORMCHECKBOX  Access control to locations within the facility FORMCHECKBOX  Crowd control inside the facility3. Exterior physical security of location FORMCHECKBOX  Specialized unit needs (canine, explosive ordnance disposal, tactical, traffic, etc.) FORMCHECKBOX  Additional physical barriers (necessity and/or identification of source) FORMCHECKBOX  Additional lighting (necessity and/or identification of source) FORMCHECKBOX  Staging area for personnel and vehicles. FORMCHECKBOX  Vehicular traffic control (ingress and egress) FORMCHECKBOX  Crowd control, traffic management and parking outside the facility FORMCHECKBOX  Access control to facility4. Command and management FORMCHECKBOX  Establish command center for law enforcement FORMCHECKBOX  Determine radio channels FORMCHECKBOX  Ensure communication and coordination between law enforcement organizations FORMCHECKBOX  Establish shifts FORMCHECKBOX  Establish sufficient number of law enforcement officer assignments5. Evacuation plans6. Security breach plans FORMCHECKBOX 1All of the above numbered items have been addressed and documented. FORMCHECKBOX 0.5Two to five of the six numbered items from above have been addressed and documented. FORMCHECKBOX 0Less than two of the numbered items above have been addressed.NOTES: FORMTEXT       6.4Badging procedures are in place for all personnel responding to a public health event involving medical materiel and resources. FORMCHECKBOX  Badging procedures identify by: FORMCHECKBOX  Name FORMCHECKBOX  Role FORMCHECKBOX  Venue FORMCHECKBOX  Access FORMCHECKBOX  Just-in-time training on badging procedures FORMCHECKBOX  Handling of spontaneous (not pre-event identified) volunteers FORMCHECKBOX 1The local jurisdiction has documented procedures that address both pre-event and spontaneous volunteers and has just-in-time training on badging procedures. FORMCHECKBOX 0The local jurisdiction does not have any badging procedures documented.NOTES: FORMTEXT       6.5Site-specific security plans have been developed for dispensing sites and/or regional distribution sites (if applicable). FORMCHECKBOX 1All dispensing sites and/or regional distribution sites have complete site-specific security plans. FORMCHECKBOX 0.550 % or more of the dispensing sites and/or regional distribution sites have complete site-specific security plans. FORMCHECKBOX 0Less than 50%of the dispensing sites and/or regional distribution sites have complete site-specific security plans.NOTES: FORMTEXT      SECTION SIX: Points  FORMTEXT       Divided by 5 =  FORMTEXT       SECTION SEVEN: REGIONAL/LOCAL DISTRIBUTION SITE (12%) **IF APPLICABLE**7.1Local Jurisdiction has a Regional Distribution Site (RDS) strategy that expedites the movement of medical material to the PODs and hospitals and/or alternate care facilities: FORMCHECKBOX  Adequate RDS facilities have been identified to ensure rapid delivery of medical material FORMCHECKBOX  Primary and backup locations have been identified FORMCHECKBOX  Locations are based on time and distance FORMCHECKBOX  Locations are based on population FORMCHECKBOX 1Strategically located RDS sites (show sites plotted on a local map) have been secured and feasible timelines for rapid movement of medical materials have been established. FORMCHECKBOX 0.5An RDS plan is being developed but incomplete. FORMCHECKBOX 0There is not a RDS plan that accounts for the movement of medical materiel.NOTES: FORMTEXT       7.2RDS facilities have been reviewed and approved for use by state SNS Coordinator using an established Site Survey Tool. FORMCHECKBOX 1All locations have been reviewed and approved for use by the state SNS Coordinator. FORMCHECKBOX 0.5At least half of all locations have been reviewed and approved for use by the state SNS Coordinator. FORMCHECKBOX 0Less than half of all locations have been reviewed and approved for use by the state SNS Coordinator.NOTES: FORMTEXT       7.3Written agreements are established for all approved RDS sites identified in 7.2. FORMCHECKBOX 1The local jurisdiction has a signed written agreement with all RDS sites. FORMCHECKBOX 0.5The local jurisdiction has a signed written agreement with at least half of the RDS sites. FORMCHECKBOX 0The local jurisdiction has a signed written agreement with less than half of the RDS sites.NOTES: FORMTEXT       7.4The following RDS manager/leader and back-up staff have been identified for each RDS facility and staff POC is documented: (0.5 points for each position for a total of 8 points includes both primary and back-up)POSITIONPRIMARYBACK-UPRDS Manager/Leader FORMCHECKBOX  FORMCHECKBOX Security Manager/Leader FORMCHECKBOX  FORMCHECKBOX Safety Manager/Leader FORMCHECKBOX  FORMCHECKBOX Communications/IT Manager /Leader FORMCHECKBOX  FORMCHECKBOX Inventory Control Manager/Leader FORMCHECKBOX  FORMCHECKBOX Shipping/Receiving Manager/Leader FORMCHECKBOX  FORMCHECKBOX Pick Team Manager/Leader FORMCHECKBOX  FORMCHECKBOX Quality Control Manager/Leader FORMCHECKBOX  FORMCHECKBOX NOTES: FORMTEXT       7.5RDS Leaders/Managers and back-ups have job action guide and have been trained in RDS operations.All RSS Leaders/Managers and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All RDS Leaders/Managers and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All RDS Leaders/Managers and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for RDS Leaders/Managers and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.6Safety Manager/Leader and back-ups have job action guide and have been trained in their RDS function.All Safety managers/leaders and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Safety managers/leaders and their back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Safety managers/leaders and their back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Safety managers/leaders and their back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.7Communications/IT Support and back-ups have job action guide and have been trained in RDS operations.All Communications/IT Support and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Communications/IT Support and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Communications/IT Support and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Communications/IT Support and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.8Inventory Manager/Leader and back-ups have job action guide and have been trained in RDS operations.All Inventory Manager/Leader and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Inventory Manager/Leader and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Inventory Manager/Leader and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Inventory Manager/Leader and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.9Shipping/Receiving Manager/Leader and back-ups have job action guide and have been trained in RDS operations.All Shipping/Receiving Manager/Leader and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Shipping/Receiving Manager/Leader and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Shipping/Receiving Manager/Leader and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Shipping/Receiving Manager/Leader and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.10Pick Team Manager/Leaders and back-ups have job action guide and have been trained in RDS operations.All Pick Team Manager/Leaders and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Pick Team Manager/Leaders and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Pick Team Manager/Leaders and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Pick Team Manager/Leaders and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.11Quality Control Managers/Leaders and back-ups have job action guide and have been trained in RDS operations.All Quality Control Managers/Leaders and their back-ups have: FORMCHECKBOX  A job action guide FORMCHECKBOX  Trained in RDS operations FORMCHECKBOX  RDS operations training is documented FORMCHECKBOX 1All Quality Control Managers/Leaders and back-ups have a job action guide, have been trained in RDS operations and training is documented FORMCHECKBOX 0.5All Quality Control Managers/Leaders and back-ups have a job action guide and have been trained in RDS operations but training documentation is not available for review.  FORMCHECKBOX 0A job action guide is not available for Quality Control Managers/Leaders and back-ups and staff have not been trained in their RDS function.NOTES: FORMTEXT       7.12Call-down lists for 24/7 operations for all RDS Managers and operational staff/volunteers are reviewed for accuracy and tested quarterly. FORMCHECKBOX 1Documented call-down lists are reviewed for accuracy and tested quarterly and corrections to call-down lists are documented. FORMCHECKBOX 0.5Documented call-down lists are reviewed for accuracy quarterly. FORMCHECKBOX 0There is no documentation available that verifies staff call-down lists are reviewed quarterly.NOTES: FORMTEXT       7.13Just-in-time (JIT) training materials have been developed for each of the RDS functions to familiarize personnel working within those functions: FORMCHECKBOX  Safety FORMCHECKBOX  Quality Control FORMCHECKBOX  Shipping/Receiving FORMCHECKBOX  Inventory Management FORMCHECKBOX  Communications/IT FORMCHECKBOX  Other functions, as appropriate FORMCHECKBOX  Pick Teams FORMCHECKBOX 1Training materials have been developed for all of the RDS functions. FORMCHECKBOX 0.5Training materials have been developed for 4 or more of the RDS functions. FORMCHECKBOX 0Less than four of the training materials have been developed for the RDS functions.NOTES: FORMTEXT       7.14An inventory of material handling equipment for each RDS site should be documented along with a list of materials/supplies that need to be procured and/or delivered at the time of event. FORMCHECKBOX 1An inventory listing containing appropriate material handling equipment is available for 100% of the RDS sites. FORMCHECKBOX 0.5An inventory listing is available for 50% or more of the RDS sites. FORMCHECKBOX 0An inventory listing is not available or available for less than 50% of the RDS sites.NOTES: FORMTEXT       7.15An inventory of office equipment for each RDS site should be documented along with a list of materials/supplies that will need to be delivered and/or procured at time of event. FORMCHECKBOX 1An inventory listing containing appropriate office equipment is available for 100% of RDS sites.  FORMCHECKBOX 0.5An inventory listing is available for 50% or more of the RDS sites. FORMCHECKBOX 0An inventory listing is not available or available for less than 50% of the RDS sites.NOTES: FORMTEXT       7.16The local plan lists individuals who are authorized to sign for SNS materiel. FORMCHECKBOX 1The local plan identifies and documents individuals who are authorized to sign for SNS materiel. FORMCHECKBOX 0The local plan does not identify and document individuals who are authorized to sign for SNS materiel.NOTES: FORMTEXT       7.17The local plan addresses staff/volunteer management (e.g., work breaks, shift schedules, meals/snacks, lodging, family care, etc.). FORMCHECKBOX 1The local plan addresses staff/volunteer management and has written agreements with organizations providing services. FORMCHECKBOX 0The local plan does not address staff/volunteer management.NOTES: FORMTEXT      SECTION SEVEN: Points  FORMTEXT       Divided by 24 =  FORMTEXT       SECTION EIGHT: INVENTORY MANAGEMENT (9%)8.1Plan for Inventory Management System (IMS) in place with back-up. This may include inventory management software system, electronic spreadsheet, paper system FORMCHECKBOX  Inventory Management Software System FORMCHECKBOX  Electronic Spread Sheet FORMCHECKBOX  Paper System FORMCHECKBOX 1The local jurisdiction has two or more functional inventory management systems in place. FORMCHECKBOX 0.5The local jurisdiction has one functional inventory management system in place. FORMCHECKBOX 0The local jurisdiction does not have a functional inventory management system in place.NOTES: FORMTEXT       8.2All inventory staff are identified and trained in IMS functions. FORMCHECKBOX 1Inventory management staff is identified and training in IMS functions is documented.  FORMCHECKBOX 0.5Inventory management staff is identified but not trained in IMS functions. FORMCHECKBOX 0Inventory management staff have not been identified and trained. NOTES: FORMTEXT       8.3Chain of custody procedures are outlined in plan and include the process for tracking pharmaceutical lot numbers. FORMCHECKBOX 1Written procedures are documented in the plan and include process for tracking lot numbers FORMCHECKBOX 0Written procedures are incomplete or are not documented in the plan for the chain of custody of controlled substances.NOTES: FORMTEXT       8.4Procedure for chain of custody involving controlled substances received from DSNS is outlined in plan. FORMCHECKBOX 1Written procedures are documented in the plan for chain of custody of controlled substances and includes procedures for control during storage and transport from the RDS sites to all receiving sites and hospitals, as applicable. FORMCHECKBOX 0No written procedures are documented in the plan for the chain of custody of controlled substances from DSNS. FORMCHECKBOX NANot applicable for this location.NOTES: FORMTEXT       8.5Local plan lists DEA Registrant(s) to receive materiel from DSNS requiring DEA Form 222. FORMCHECKBOX 1The local jurisdiction has identified and documented more than one DEA Registrant (primary and back-up at least) to issue DEA Form 222. FORMCHECKBOX 0The local jurisdiction has not identified a DEA Registrant to issue DEA Form 222. FORMCHECKBOX NANot applicable for this location.NOTES: FORMTEXT       8.6The local inventory management system has the capability to track the following data elements:  FORMCHECKBOX  Product Description FORMCHECKBOX  Size FORMCHECKBOX  Unit of Use FORMCHECKBOX  National Drug Code (NDC) FORMCHECKBOX  Lot Number FORMCHECKBOX  Expiration Date FORMCHECKBOX 1The local jurisdiction IMS can track all of the items listed.  FORMCHECKBOX 0.5The local jurisdiction IMS can track three to five of the items listed. FORMCHECKBOX 0The local jurisdiction IMS can track two or less of the items listed.NOTES: FORMTEXT       8.7The local inventory management system can perform the following function(s): FORMCHECKBOX  Generate pick lists FORMCHECKBOX  Generate bill of lading FORMCHECKBOX  Track open and closed orders FORMCHECKBOX  Track inventory levels throughout the distribution network (*Note: if RDN does not apply and IMS system used at all PODs meets this minimum criteria, award full score (1)  FORMCHECKBOX 1The local jurisdiction IMS can track or perform all of the items listed.  FORMCHECKBOX 0.5The local jurisdiction IMS can track or perform one to three of the items listed. FORMCHECKBOX 0The local jurisdiction IMS cannot track or perform any of the items listed.NOTES: FORMTEXT      SECTION EIGHT: Points  FORMTEXT       Divided by 7 =  FORMTEXT       SECTION NINE: DISTRIBUTION (10%) **IF APPLICABLE**9.1Distribution operations manager and back-up(s) have job action guide and have been trained in their functions. FORMCHECKBOX 1A job action guide regarding distribution functions has been developed and both primary and back-up staff has received training in distribution functions. FORMCHECKBOX 0.5A job action guide regarding the distribution manager position has been developed, but no training has been conducted. FORMCHECKBOX 0Job action guide has not been developed for this position nor has training been conducted.NOTES: FORMTEXT       9.2Plan includes distribution strategy for delivery of medical materiel (such as delivery locations, routes, delivery schedule/frequency, fueling, repair, recovery, etc). FORMCHECKBOX 1The local plan includes a detailed strategy (mapping, frequency, routing, scheduling, etc.).  FORMCHECKBOX 0.5The local plan includes general strategy for distributing materiel. 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FORMCHECKBOX 1A primary agency/organization has been identified with responsibility for distributing medical materiel and a written agreement is in place. FORMCHECKBOX 0Primary agency/organization has not been identified or acknowledged by written agreement.NOTES: 9.4Back-up agency/organization has been identified distribute medical materiel and a written agreement is in place. FORMCHECKBOX 1A back-up agency/organization has been identified with responsibility for distributing medical materiel and a written agreement is in place. FORMCHECKBOX 0Back-up agency/organization has not been identified or acknowledged by written agreement.NOTES: FORMTEXT       9.5Transportation resource needs have been identified and are available to perform and support primary and re-supply activities for a medical countermeasure distribution campaign and include: FORMCHECKBOX  Number of vehicles needed FORMCHECKBOX  Number of drivers needed  FORMCHECKBOX  Types of vehicles needed FORMCHECKBOX  Type and number of support personnel needed FORMCHECKBOX 1All the identified resources above are identified and accessible. FORMCHECKBOX 0.5Two to three of the above resources are identified and accessible. FORMCHECKBOX 0Less than two of the above resources are identified and accessible.NOTES: FORMTEXT       9.6Material Handling Equipment, MHE (pallet jacks, hand carts/dollies, forklifts), has been inventoried and plans are in place to support MHE needs at dispensing sites that will receive materiel. FORMCHECKBOX 1 All dispensing sites designated to receive material have been inventoried and plans are in place to support MHE needs. FORMCHECKBOX 0.550% of all dispensing sites designated to receive material have been inventoried and plans are in place to support MHE needs. FORMCHECKBOX 0Less than 50% of dispensing sites have been inventoried and plans are in place to support MHE needs or MHE needs have not been identified. NOTES: FORMTEXT       9.7Just-in-time (JIT) training materials have been developed for the distribution functions: FORMCHECKBOX  Chain of custody protocol FORMCHECKBOX  Appropriate use of material handling equipment FORMCHECKBOX  Routing information FORMCHECKBOX  Loading and off-loading materials FORMCHECKBOX  Security/communication procedures FORMCHECKBOX 1All of the above just-in-time training materials have been developed. FORMCHECKBOX 0.5Two to four of the above just-in-time training materials have been developed. FORMCHECKBOX 0Less than two of the above just-in-time training materials have been developed. NOTES: FORMTEXT      SECTION NINE: Points  FORMTEXT       Divided by 7 =  FORMTEXT       SECTION TEN: MEDICAL COUNTERMEASURE DISPENSING (22%)10.1The local mass prophylaxis/dispensing plan details the procedures for the following operational issues: FORMCHECKBOX  Dispensing multiple regimens to the public FORMCHECKBOX  Collection of minimum data elements for each unit of medication dispensed FORMCHECKBOX  Processing symptomatic individuals FORMCHECKBOX  Processing unaccompanied minors FORMCHECKBOX  Processing non-English speakers/hearing impaired/visually impaired/functionally illiterate FORMCHECKBOX  Procedures for shift hours and shift change FORMCHECKBOX  Monitoring information on adverse events  FORMCHECKBOX 1All of the elements listed are included in the local medical countermeasure dispensing plan. FORMCHECKBOX 0.5Four to six of the elements listed are included in the local medical countermeasure dispensing /dispensing plan. FORMCHECKBOX 0Three or less of the elements listed are in the local mass prophylaxis/dispensing plan.NOTES: FORMTEXT       10.2The local mass prophylaxis/dispensing plan include a rapid dispensing strategy for dispensing at dispensing/POD sites. FORMCHECKBOX 1Rapid dispensing methods, policies and procedures are documented in the plan. FORMCHECKBOX 0.5Rapid dispensing methods have been identified but policies and procedures are not outlined in the plan. FORMCHECKBOX 0Rapid dispensing methods have not been identified.NOTES: FORMTEXT       10.3Alternate dispensing modalities are included in the plan. FORMCHECKBOX 1Alternate dispensing modes have been identified and procedures are documented in the plan. FORMCHECKBOX 0.5Alternate dispensing modes have been identified but details on policies and procedures are not outlined in the plan. FORMCHECKBOX 0Alternate dispensing modes have not been identified.NOTES: FORMTEXT       10.4The local mass prophylaxis/dispensing plan include established criteria, authorization and procedures to alter dispensing model to increase throughput.  FORMCHECKBOX 1Plans are in place. FORMCHECKBOX 0Plans are not in place.NOTES: FORMTEXT       10.5The plan specifies procedures for providing prophylaxis to public health responders and critical infrastructure personnel. FORMCHECKBOX 1Public health responder and critical infrastructure prophylaxis plans are in place. FORMCHECKBOX 0Public health responder and critical infrastructure prophylaxis plans are not in place.NOTES: FORMTEXT       10.6The plan identifies and provides procedures for supplying prophylaxis to homebound and other at-risk populations. FORMCHECKBOX 1Homebound and at-risk populations are identified and prophylaxis plans are in place. FORMCHECKBOX 0Homebound and at-risk population prophylaxis is not identified or plans are not in place.NOTES: FORMTEXT       10.7There are site-specific plans for each of the dispensing/POD sites that include the following information: FORMCHECKBOX  MOU for use of the facility FORMCHECKBOX  Facility manager with contact information and procedures for accessing the site FORMCHECKBOX  Address and telephone numbers at the facility FORMCHECKBOX  Inventory of available office equipment on site FORMCHECKBOX  Inventory of available material handling equipment on site FORMCHECKBOX  Written floor plans/clinic flow charts (traditional and streamlined) FORMCHECKBOX  Specific delivery location identified w/plans to ensure 24/7 unblocked access by delivery trucks FORMCHECKBOX 1All dispensing sites have a site-specific plan. FORMCHECKBOX 0.550% of dispensing sites have a site-specific plan. FORMCHECKBOX 0Less than 50% of the dispensing sites have specific-plans.NOTES: FORMTEXT       10.8The plan specifies procedures for making the following items available at every dispensing/POD site before dispensing starts: FORMCHECKBOX  Drug fact sheets FORMCHECKBOX  Office equipment FORMCHECKBOX  Agent fact sheets FORMCHECKBOX  Command and Control vests or other identifiers FORMCHECKBOX  Dispensing/medical supplies FORMCHECKBOX  Communication equipment FORMCHECKBOX  Name/Address/Patient History (NAPH) forms FORMCHECKBOX  Signs (interior and exterior) FORMCHECKBOX  Office supplies FORMCHECKBOX  Crowd and traffic control equipment FORMCHECKBOX 1Plans and procedures address all of the applicable items to make them available at each dispensing site at time of event. FORMCHECKBOX 0.5Plans and procedures address 75% of the applicable items to make them available at each dispensing site at time of event. FORMCHECKBOX 0Plans and procedures address less than 75% of the applicable items.NOTES: FORMTEXT       10.9Core management teams with back-ups have been identified and trained for each dispensing/POD site and have received training annual. FORMCHECKBOX 1Core management teams have been identified and trained for all dispensing/POD sites. FORMCHECKBOX 0.5Core management teams have been identified and trained more than 50% of the dispensing/POD sites. FORMCHECKBOX 0Core management teams have been identified for less than 50%of the dispensing/POD sites.NOTES: FORMTEXT       10.10Personnel other than core management teams are available to staff dispensing/POD sites. FORMCHECKBOX 1Personnel are available to staff all of the dispensing/POD sites. FORMCHECKBOX 0.5Personnel are available to staff at least 50%of the dispensing/POD sites. FORMCHECKBOX 0Personnel are available to staff less than 50% of the dispensing/POD sites.NOTES: FORMTEXT       10.11Volunteer/staff database is maintained and current: FORMCHECKBOX  There are enough people in the database for all POD sites, including shift changes. FORMCHECKBOX  The database includes enough extra people to compensate for absent individuals. FORMCHECKBOX 1The database has sufficient volunteers identified to staff all POD sites, including shift changes. FORMCHECKBOX 0.5The database has at least 50% of the number of people needed to staff all the PODs based on the jurisdiction s staffing  FORMCHECKBOX 0A database is absent or has less than 50% of the people needed based on the jurisdiction s staffing model.NOTES: FORMTEXT       10.12The plan includes Job Action Guide and Just-In-Time training materials to support each staff position for all dispensing/POD roles identified in the plan. POD roles may include common POD roles, such as: FORMCHECKBOX  POD Manager FORMCHECKBOX  Triage Team FORMCHECKBOX  Runners FORMCHECKBOX  IT/Communications FORMCHECKBOX  Greeter/Triage Team FORMCHECKBOX  Others, as applicable FORMCHECKBOX  Safety Officer FORMCHECKBOX  Forms/Data Collection FORMCHECKBOX   FORMTEXT       FORMCHECKBOX  Logistics Officer FORMCHECKBOX  Dispensing Team FORMCHECKBOX   FORMTEXT       FORMCHECKBOX  Greeters FORMCHECKBOX  Inventory Control FORMCHECKBOX   FORMTEXT       FORMCHECKBOX 1Job action guides and just-in-time training materials for all identified POD roles are documented and available for review. FORMCHECKBOX 0.5Job action guides for six or more of the identified POD roles are documented and available for review. FORMCHECKBOX 0Job action guides for less than six of the identified POD roles are documented and available for review.NOTES: FORMTEXT       10.13The local plan includes details or reference to staff/volunteer management procedures and support (for example, work breaks, shift schedules, meals/snacks, lodging, family care, etc.). FORMCHECKBOX 1The local plan addresses staff/volunteer management and has written agreements with organizations providing services. FORMCHECKBOX 0The local plan does not address staff/volunteer management.NOTES: FORMTEXT      SECTION TEN: Points  FORMTEXT       Divided by 13 =  FORMTEXT       SECTION ELEVEN: HOSPITALS AND ALTERNATE CARE FACILITES COORDINATION (3%) **IF APPLICABLE**11.1Process established for hospitals and alternate care facilities to be informed on how to procure emergency medical materiel. FORMCHECKBOX 1Documentation is available verifying that hospitals and alternate care facilities have been informed of procedures. FORMCHECKBOX 0Documentation is not available verifying that hospitals and alternate care facilities have been informed of procedures.NOTES: FORMTEXT       11.2 The emergency medical materiel request process has been documented including the identification and quarterly update of personnel authorized to request materiel for hospitals and alternate care facilities.  FORMCHECKBOX 1100% of the hospitals or alternative care sites have either identified personnel authorized to request materiel and contact information is updated quarterly or have implemented HICS and documented the emergency request process in emergency response plans. FORMCHECKBOX 0.5At least 50% of the hospitals or alternative care sites have either identified personnel authorized to request materiel and contact information is updated quarterly or have implemented HICS and documented the emergency request process in emergency response plans. FORMCHECKBOX 0Less than 50% of the hospitals or alternative care sites have either identified personnel authorized to request materiel and contact information is updated quarterly or have implemented HICS and documented the emergency request process in emergency response plans.NOTES: FORMTEXT       11.3The local SNS plan includes documented procedures for hospitals and alternate care facilities to request emergency medical materiel.  FORMCHECKBOX 1Procedures for hospital and alternate care facility to request medical materiel are included in the plan.  FORMCHECKBOX 0Procedures for hospital and alternate care facility to request medical materiel are not included in the plan.NOTES: FORMTEXT       11.4Hospitals and alternate care facilities are trained annually on the emergency medical materiel request procedures. FORMCHECKBOX 1All of hospitals and alternate care facilities have been trained on emergency medical materiel request procedures. FORMCHECKBOX 0.5More than 50% of the hospitals and alternate care facilities have been trained on emergency medical materiel request procedures. FORMCHECKBOX 0Less than 50% of the hospitals and alternate care facilities have been trained on emergency medical materiel request procedures.NOTES: FORMTEXT       11.5Hospitals and alternate care facilities request procedures have been exercised. FORMCHECKBOX 1Request procedures have been exercised and can be verified for all hospitals and alternate care facilities and a corrective action plan addressing identified discrepancies is in place. FORMCHECKBOX 0.5Request procedures have been exercised and can be verified for 50% or more of the hospitals and alternate care facilities and a corrective action plan addressing identified discrepancies are in place. FORMCHECKBOX 0Request procedures have been exercised for less than 50% of the hospitals and alternate care facilities.NOTES: FORMTEXT      SECTION ELEVEN: Points  FORMTEXT       Divided by 5 =  FORMTEXT       SECTION TWELVE: TRAINING, EXERCISE, AND EVALUATE (8%)12.1Primary and back-up staff have been assigned to lead, plan and oversee public health and medical countermeasure distribution and dispensing emergency preparedness-related training, exercise and evaluation. FORMCHECKBOX 1Personnel have been assigned. FORMCHECKBOX 0Personnel have not been assigned.NOTES: FORMTEXT       12.2The local jurisdiction has developed, identified and/or documented emergency preparedness training resources and opportunities related to medical countermeasure distribution and dispensing. Information includes course objectives, target audiences (i.e. public health staff, volunteers, etc) and scheduling.  FORMCHECKBOX 1The local jurisdiction has documented training resources and opportunities supporting medical countermeasure distribution and dispensing and other SNS specific activities. FORMCHECKBOX 0The local jurisdiction has not documented training resources and offerings that support medical countermeasure distribution and dispensing and other SNS specific activities.NOTES: FORMTEXT       12.3The local jurisdiction conducts training and exercise plan workshops (TEPW) annually and has developed a multi-year training and exercise plan in accordance with the Department of Homeland Security Exercise and Evaluation Program (HSEEP) guidance. FORMCHECKBOX 1The local jurisdiction conducts annual training and exercise workshop and has developed a multi-year training and exercise plan in accordance with HSEEP.  FORMCHECKBOX 0The local jurisdiction does not conduct annual training and exercise workshops and has not developed a multi-year training and exercise plan in accordance with HSEEP.NOTES: FORMTEXT       12. 4The multi-year training and exercise plan is updated annually and incorporates medical countermeasure distribution and dispensing trainings, drills, discussion-based and operational exercises. FORMCHECKBOX 1A multi-year training and exercise plan incorporating medical countermeasure distribution and dispensing activities that follow HSEEP guidance is available for review. FORMCHECKBOX 0.5A multi-year training plan and exercise plan incorporating medical countermeasure distribution and dispensing activities has been developed and is available for review but has not been developed in accordance with HSEEP guidance.  FORMCHECKBOX 0A multi-year training and exercise plan is not developed and available for review or does not incorporate medical countermeasure distribution and dispensing activities that are to be tested and evaluated. NOTES: FORMTEXT       12.5Action Report/Improvement Plans (AAR/IP) are developed in accordance with HSEEP guidance.,  FORMCHECKBOX 1Discussion-based and/or operational  based exercises incorporating medical countermeasure distribution and dispensing activities are conducted and after action reports/improvement plans are completed in accordance with HSEEP principles and standards. FORMCHECKBOX 0.5Discussion-based and/or operational  based incorporating medical countermeasure distribution and dispensing activities are conducted but after action reports and and/or operational  based exercises are not completed in accordance with HSEEP principles and standards.  FORMCHECKBOX 0Discussion-based and operational exercises incorporating medical countermeasure distribution and dispensing activities are not performed or documented NOTES: FORMTEXT       12.6The local jurisdiction can demonstrate that annual training has been performed for the following SNS functional areas or processes. (0.5 points for each element  6.5 total points)FUNCTIONTrained AnnuallyFUNCTIONTrained AnnuallyOverall SNS Planning Elements FORMCHECKBOX Security Operations  FORMCHECKBOX Management of Operations FORMCHECKBOX Inventory Management System FORMCHECKBOX Local-State Requesting SNS Procedures FORMCHECKBOX Regional/Local RDS Operations (If Applicable) FORMCHECKBOX POD-Local Requesting SNS Procedures FORMCHECKBOX Distribution Operations (If Applicable) FORMCHECKBOX Communications Plan (Tactical)  FORMCHECKBOX Hospitals and Alternate Care Facilities Coordination FORMCHECKBOX Public Information and Communication  FORMCHECKBOX NOTES: FORMTEXT      SECTION TWELVE: Points  FORMTEXT       Divided by 11.5 =  FORMTEXT       Scoring Instructions Divide points scored in an individual section by total points for that section. This gives a section score. To determine overall score, multiply the section score by the section weight for a weighted score. Sum of all weighted scores is the Overall Score. OVERALL SCORESectionFunctionPointsMax PointsSection ScoreSection WeightWeighted Score1Developing a Plan with SNS Elements FORMTEXT      6 FORMTEXT      .03 FORMTEXT      2Management of SNS FORMTEXT      6 FORMTEXT      .10 FORMTEXT      3Requesting SNS FORMTEXT      5 FORMTEXT      .03 FORMTEXT      4Communications Plan (Tactical) FORMTEXT      6 FORMTEXT      .03 FORMTEXT      5Public Information and Communication FORMTEXT      7 FORMTEXT      .07 FORMTEXT      6Security FORMTEXT      5 FORMTEXT      .10 FORMTEXT      7Regional/Local Distribution Site FORMTEXT      24 FORMTEXT      .12 FORMTEXT      8Inventory Management  FORMTEXT      7  FORMTEXT      .09 FORMTEXT      9Distribution FORMTEXT      7 FORMTEXT      .10 FORMTEXT      10Medical Countermeasure Dispensing FORMTEXT      13 FORMTEXT      .22 FORMTEXT      11Hospital and Alternate Care Facilities Coordination FORMTEXT      5 FORMTEXT      .03 FORMTEXT      12Training and Exercise FORMTEXT      11.5 FORMTEXT      .08 FORMTEXT      Overall Score = Sum of 12 Function Scores = FORMTEXT       N/A Instructions If Section 7 is not applicable, add all sections except for Regional/Local Distribution Site. If Section 9 is not applicable, add all sections except for Distribution. If Section 11 is not applicable, add all sections except for Hospitals and Alternate Care Facilities Coordination. Use this table if you have one or multiple sections that are not applicable: If Section 7 is N/ADivide sum of Weighted Score by .86If Section 9 is N/ADivide sum of Weighted Score by .90If Section 11 is N/ADivide sum of Weighted Score by .97If Sections 7 and 9 is N/ADivide sum of Weighted Score by .76If Sections7 and 11 are N/ADivide sum of Weighted Score by .87If Sections 9 and 11 are N/ADivide sum of Weighted Score by .83If Sections 7, 9 and 11 are N/ADivide sum of Weighted Score by .73 Baseline Data TIP explanation from page 1. Local population covered by local planning jurisdiction s medical countermeasure dispensing plan. TIP The most current US Census population and citation that reflects the population covered by the jurisdictional SNS Plan. If this local planning jurisdiction is a health district, please define the counties or other criteria for identification of population coverage in the NOTES section. Hourly throughput needed to provide prophylaxis to 100% of the population within 48 hours of federal emergency activation. TIP The needed throughput to prophylax 100% of the jurisdictional population is a critical planning consideration and should be based on estimates for hourly throughput of the total jurisdictional population per total hours of POD operation. The hours for operation will be less than 36 and dependent on estimates distribution times to provide material to local level POD sites. 2A. TIP Time for operation of PODs less time for SNS, state and local distribution. The operational window will 48 hours less 12 hours for SNS and additional estimates for state and local delivery. Total number of Points of Dispensing (PODs) identified to cover 100% of the population. TIP Total PODs (open PODs) that have been identified to serve 100% of the population identified in #1. Calculated combined hourly operational throughput, based on modeling, exercise or estimate, to provide prophylaxis to 100% of the jurisdiction s population within 48 hours through operation of all general population PODs identified in the local planning jurisdiction. TIP Throughput should be defined as the number of persons expected to visit the POD (i.e. prophylaxed) per hour. Depending on the PODs in your jurisdiction, estimates can be calculated or estimated in several ways. For jurisdictions that have all similar sized PODs they can submit an estimate of the number of people prophylaxed at an individual POD per hour and make a notation that this is single site estimate that is applicable to all PODs. For jurisdictions that have POD sites that vary significantly in size, layout and throughput, a combined total estimated of throughput should be provided. Indications of use of Head of Household dispensing and number of regimens per HOH are to be identified. Please refer to the DSNS Point of Dispensing (POD) Standards, April 2008 for additional considerations. Number of total PODs identified with appropriate authorization. TIP Number of PODs with established MOA's, MOUs or other written agreements in place to support use during public health emergency. Number of total PODs with documented site-specific plans. TIP Number of PODs with completed site specific operational plans. Number of PODs with in-progress or incomplete plans should be placed under NOTES section. Number of total POD sites with identified primary and back-up management teams. TIP Number of PODs with primary and back-up management staff identified and rostered. Estimated number of personnel needed to staff 100% of POD functions for a mass prophylaxis campaign and/or medical supplies management and distribution. TIP Estimated number of personnel needed to staff all POD operational functions. Current number of personnel on hand to staff POD functions for a mass prophylaxis campaign and/or medical supplies management and distribution. TIP Number of personnel currently available through PH or volunteer databases to staff operations and security at all PODs. 11. Population covered by all Closed POD alternate dispensing modalities. (9b-h above) TIP Total population to receive prophylaxis at Closed POD locations identified in 9b-h. Clarification or additional detail can be placed in Notes section.  Additional clarification is provided for selected Baseline Data questions through Excel ToolTip and through comment on Page 27.     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