South Central Healthcare Coalition Membership for 2021-22

As per the Annual Work Plan a comprehensive list of Coalition members must be maintained. In order for the Readiness & Response Coordinator to comple this task, please complete this short survey.

The SC HCC exists to develop, enhance, and promote healthcare surge capabilities through communication, planning, training coordination, and collaboration with Coalition partners.

By joining the SC HCC, you will receive pertinent information from the Coalition about meetings, training and exercise opportunities, and regional best practices, as well as lessons learned. The information you provide will also serve as a tool to aid in the response to a real event. This information will only be shared with authorized agencies for response purposes.

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* 1. Agency Name and Location Information

Agency Name

Street Address

City/Town

State/Province

ZIP/Postal Code

County

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* 2. Your Contact Information

First Name

Last Name

Job Title

Work Email Address

Work Phone Number (Direct if Available)

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* 3. As per the Annual Work Plan, two redundant drills must be conducted every year. The results are then provided to KDHE and ASPR. Please provide a cell phone number that you can receive this notification on.

Cell Phone Number

Secondary Email Address

Secondary Phone Number

Secondary Cell Phone Number

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* 4. Are you able to receive text messages on the Cell Phone Number(s) listed in Question #3 Above?

Yes

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* 5. Who would be the Primary Point of Contact to the SC HCC for your Agency (Name Only)?

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* 6. If your mailing address is different than Question #1 above, please provide the following.

Address

Address 2/Suite Number

City/Town

State/Province

ZIP/Postal Code

County

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* 7. Is your Agency a New or Existing SC HCC Member

New

Existing

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* 8. If your Agency is an existing SC HCC Member, do you know when your Agency joined the HCC?

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* 9. Agency Member Type

Behavioral Health Services & Organizations

Community Emergency Response Team (CERT) & Medical Reserve Corps (MRC)

Dialysis Centers & Regional Centers for Medicare & Medicaid Services (CMS) - Funded
End-Stage Renal Disease (ERSD) Networks

Emergency Management

Emergency Medical Services

Federal Facilities (e.g., DoD Hospitals, VA Medical Centers)

Home Health Agency

Hospital - Acute Care

Hospital - Critical Access

Hospital - Non-Acute Care

Hospital - Trauma Center

Infrastructure Company

Jurisdictional Partners (including Cities, Counties, and Tribes)

Local Chapter of Health Care Professional Organization

Local Public Safety Agency

Medical & Device Manufacturers and Distributors

Non-Governmental Organization (NGO)

Outpatient Health Care Delivery Center

Primary Care Providers (including Pediatric and Women's Health Care Providers)

Public Health Department

Public or Private Payers

Schools & Universities (including Academic Medical Centers)

Skilled Nursing, Nursing & Long-Term Care Facility

Specialty Patient Referral Center

Support Service Provider

Other Organizations (please specify)

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* 10. Have you completed the ICS-100: Introduction to the Incident Command System training?

Yes

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* 11. Have you completed the ICS-200: ICS for Single Resources and Initial Action Incidents training?

Yes

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* 12. Have you completed the IS-700: National Incident Management System, An Introduction training?

Yes

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* 13. Have you completed the IS-800: National Response Framework, An Introduction training?

Yes

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* 14. Have you completed the ICS-300: Intermediate ICS for Expanding Incidents training?

Yes

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* 15. Have you completed the ICS-400: Advanced ICS for Command and General Staff training?

Yes

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* 16. If there is a vacancy on the Executive Committee, would you like to be considered for the position?

Yes

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* 17. The SC HCC has 7 Standing Committees. Please indicated below if you have a desire to participate in any of these Committees. (You may choose more than one.)

Exercise Planning

Leadership / Finance

Educational, Marketing, and Communications

MOU (Memorandum of Understanding) Development

Plans Development

Resource Logistics

Website

South Central Healthcare Coalition Membership for 2021-22

Question Title

* 1. Agency Name and Location Information

Question Title

* 2. Your Contact Information

Question Title

* 3. As per the Annual Work Plan, two redundant drills must be conducted every year. The results are then provided to KDHE and ASPR. Please provide a cell phone number that you can receive this notification on.

Question Title

* 4. Are you able to receive text messages on the Cell Phone Number(s) listed in Question #3 Above?

Question Title

* 5. Who would be the Primary Point of Contact to the SC HCC for your Agency (Name Only)?

Question Title

* 6. If your mailing address is different than Question #1 above, please provide the following.

Question Title

* 7. Is your Agency a New or Existing SC HCC Member

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* 8. If your Agency is an existing SC HCC Member, do you know when your Agency joined the HCC?

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* 9. Agency Member Type

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* 10. Have you completed the ICS-100: Introduction to the Incident Command System training?

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* 11. Have you completed the ICS-200: ICS for Single Resources and Initial Action Incidents training?

Question Title

* 12. Have you completed the IS-700: National Incident Management System, An Introduction training?

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* 13. Have you completed the IS-800: National Response Framework, An Introduction training?

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* 14. Have you completed the ICS-300: Intermediate ICS for Expanding Incidents training?

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* 15. Have you completed the ICS-400: Advanced ICS for Command and General Staff training?

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* 16. If there is a vacancy on the Executive Committee, would you like to be considered for the position?

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* 17. The SC HCC has 7 Standing Committees. Please indicated below if you have a desire to participate in any of these Committees. (You may choose more than one.)

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* 18. Do you have any recommendations for the SC HCC that would assist your agency?