2015 Exercise Participation Survey

In preparation for the exercise on November 19th the Public Health Department Emergency Preparedness Team is requesting that each facility/agency completes the following questions. This information will let the Public Health Department know how your facility/agency will be participating during the exercise on November 19th and help with our planning efforts.

This year’s exercise scenario is an anthrax attack. Please join disaster response partners, cities and the Public Health Department as we prepare our communities for an weaponized anthrax attack.

If you have any questions about the exercise or this form please contact Stacey Rosenberger at stacey.rosenberger@sbcphd.org or (805) 681-4912.

Question Title

* 1. Address

Name

Facility/Agency

Email Address

Question Title

* 2. Type of Provider:

Hospital

Skilled Nursing Facility

Clinic

Surgery Center

Home Health

Long Term Care

Dialysis

Public Health Clinic

Other (please specify)

Question Title

* 3. Will your facility/agency be participating in the November 19th Exercise?

Yes, my facility/agency will be participating in the November 19th Exercise.

No, my facility/agency will NOT be participating in the November 19th Exercise.

Please read the following before answering the next question.

A "Closed POD" or Point of Dispensing is a non-medical or medical dispensing site that will provide medication to the staff and families of a business, facility, or agency during a public health emergency that requires large scale immediate mass prophylaxis in order to preserve life and health.

A "Closed POD" could also provide medication to patients, clients, students, contractors or others associated with the business or agency. In most cases this does not include your outpatients unless they are homebound.

Benefits of a "Closed POD":
- allows facility or agency to quickly distribute emergency medications to protect employees, families, clients and students
- allows facility or agency to continue their operations

Question Title

* 4. How will your facility/agency participate in the November 19th Exercise?
If you choose to participate your facility/agency must Respond to CAHAN alert, Submit Status Report and Resource Request for minimal participation. All other forms of participation are additional. Please check all that apply to your facility/agency.

Minimal Participation- Respond to CAHAN alert, Submit Status Report and Resource Request.

Receive 'faux' antibiotics and exercise your facility/agency Closed POD plan.

Exercise surge of patients using paper, balloon or volunteer 'patients'.

Open Hospital or Clinic Command Center.

Other (please specify)

Question Title

* 1. Address

Question Title

* 2. Type of Provider:

Question Title

* 3. Will your facility/agency be participating in the November 19th Exercise?

Question Title

Question Title

* 5. Questions? Please include any questions you have about the exercise below and they will be answered in a timely manner.

* 5. Questions?
Please include any questions you have about the exercise below and they will be answered in a timely manner.