0990-0302 1_Unit Profile

Unit Profile

Collection Tool

Form Approved

OMB No. 0990-0302

Exp. Date XX/XX/20XX

Element	Data Element	Collection Tool
	Sub Factor 1.1 Determine Jurisdiction Served Jurisdiction Type: Mixed, Rural/Frontier, Suburban, Tribal, Urban	Unit Profile Data Elements
	Sub Factor 1.1 Determine Jurisdiction Served Coverage Type: City/Town, County	Unit Profile Data Elements
	Sub Factor 1.1 Determine Jurisdiction Served Select Jurisdiction: Add State, Select County or Zip Code, Add Selected County or Zip Codes	Unit Profile Data Elements
	Sub Factor 1.1 Determine Jurisdiction Served Jurisdiction Notes: Free Text Box	Unit Profile Data Elements
	Sub Factor 1.3 Develop Mission Statement Unit Mission Statement: Free Te xt Box	Unit Profile Data Elements
	Sub Factor 1.4 Determine Goals and ‘SMART’ Objectives Unit Goals/Objectives: Free Text Box	Unit Profile Data Elements
	Sub Factor 2.1 Develop Working Partnerships and Affiliations with Organizations in the Community Partner Organization –Drop Down List Health Department Board of Health Emergency Management Agency Citizen Corps Council Volunteer Center Hospital/Health System Non-Governmental Organizational Medical/Professional Society Civic Organization Fire Department/Fire Protection District Law Enforcement/Agency EMS Agency Regional Planning Council/Commission Other College/University Other Local Governmental Agency/Department American Red Cross Chapter Faith-Based Organization Private Sector –Business/Corporation State Governmental Agency/Department Urban Area Security Initiatives Cities Readiness Initiative (CRI) Strategic National Stockpile (SNS) National Disaster Medical System (NDMS) HOSA-Future Health Professionals AmeriCorps/VISTA/Senior Corps Animal Health/Veterinary Agency or Organization County/State Animal Response Teams (CART/SART) High School Military Unit/Organization Tribal Organization/Agency Community Health Center	Unit Profile Data Elements
New	Sub Factor 2.1 Develop Working Partnerships and Affiliations with Organizations in Community “Is your MRC unit included in your jurisdiction’s Emergency Operations Plan(s)?”	Unit Profile Data Elements
	Sub Factor 3.2 Identify and Pursue Funding and/or Resources Funding Sources: In-kind from sponsor organization In-kind from partner organization Financial contributions/grants from private sector (business and industry) Financial contributions/grants from foundations and other non-governmental organizations Financial contributions/grants from local governmental agencies Financial contributions/grants from state governmental agencies Financial contributions/grants from federal governmental agencies	Unit Profile Data Element
	Sub Factor 4.1 Identify and Appoint MRC Leadership User Demographics: Name, Title, Organization, Address 1, Address 2, Phone, Fax, Email Address, Leader Type (Employee/Volunteer), Number of Hours per Week focus on MRC	User Profile Data Elements
	Sub Factor 4.4 Determine Unit Composition Number of Volunteers: Acupuncturist Chaplain/Clergy Clinical Social Worker Dentists EMS Professionals Licensed Practical Nurse/Licensed Vocational Nurse Mental Health Counselor/Therapist Non-Public Health/Non-Medical Nurse Practitioner Other Public Health/Medical Pharmacist Physician Physician Assistant Psychiatrist Psychologist Registered Nurse Respiratory Therapist Veterinarian Veterinarian Technician	Unit Profile Data Elements
	Sub Factor 4.4 Determine Unit Composition Are your MRC members included, or do you plan to include them in the State Volunteer Registry (ESAR-VHP)? (Yes/No selection)	Unit Profile Data Element
	Sub Factor 4.4 Determine Unit Composition Does your MRC unit allow youth membership (under 18 years of age)? (Yes/No selection)	Unit Profile Data Element
New	Sub Factor 6.1 Screen and Select Volunteer for MRC Membership To What Level are your unit’s MRC volunteers credentialed by either the local unit or the state? (Drop Down List Selection) with definition Level 1: Identified volunteers who are clinically active in a hospital, either an employee or by having hospital privileges Level 2: Identifies volunteers who are clinically active in a wide variety of settings, such as clinics, nursing homes and shelters Level 3: Identified volunteers who meet the basic qualifications necessary to practice in the state in which they are registered Level 4: Identified volunteers who have experience or education that would be useful not controlled by scope of practice laws (may include health professions students or retired health professionals who no longer hold a license Level 5: Do not verify credentials	Unit Profile Data Element
	Sub Factor 6.1 Screen and Select Volunteer for MRC Membership Does your MRC unit require “Fit-for-duty” checks (i.e. physical and mental)? (Yes/No selection)	Unit Profile Data Element
	Sub Factor 7.1 Develop a Training Plan Does your MRC unit utilize the MRC Core Competencies? (Yes/No selection)	Unit Profile Data Element
	Sub Factor 7.1 Develop a Training Plan Does your MRC unit utilize MRC-TRAIN or your state affiliated TRAIN? (Yes/No selection)	Unit Profile Data Element
	Sub Factor 7.1 Develop a Training Plan Is your MRC unit compliant or working toward compliance with NIMS requirements? (Yes/No selection)	Unit Profile Data Element
	Sub Factor 7.1 Develop a Training Plan Does your MRC unit participate in training exercises/drills with local partners? (Yes/No selection)	Unit Profile Data Element
New	Sub Factor 7.1 Develop a Training Plan Which of the following competency areas does your unit have required training? (Select all that apply) Personal and family preparedness for disasters and public health emergencies Knowledge of personal safety measures that can be implemented in a disaster or public health emergency Knowledge of one’s expected role(s) in organizational and community response plans activated during a disaster or public health emergency Communicate effectively with others in a disaster or public health emergency Knowledge of surge capacity assets consistent with one’s role in organizational, agency, and/or community response plans Knowledge of principles and practices for the clinical management of all ages and populations affected by disasters and public health emergencies, in accordance with professional scope of practice Situational awareness of actual/potential health hazards before, during and after a disaster or public health emergency Knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies Knowledge of ethical principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency Knowledge of legal principles to protect the health and safety of all ages, populations and communities affected by a disaster or public health emergency Knowledge of short- and long-term considerations for recovery of all ages, populations, and communities affected by a disaster or public health emergency	Unit Profile Data Element
	Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers Do you track your MRC member’s willingness to deploy outside of the local jurisdiction? (Yes/No)	Unit Profile Data Element
New	Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers Does your unit have mobilization plan?	Unit Profile Data Element
New	Sub Factor 8.2 Develop Procedures to Organize, Assemble and Deploy Volunteers Does your unit have a demobilization plan?	Unit Profile Data Element
	Sub Factor 11.2 Determine Volunteer legal Protections Legal Protections Row Headers Liability/Malpractice Workers Compensation Re-employment Rights No Legal Protections Legal Protections Column Headers During declared emergencies During Non-Emergency/Public Health Event During Training Activities All MRC Related Activities	Unit Profile Data Element
	Sub Factor 11.2 Determine Volunteer Legal Protections (Click all that apply) Source of Legal Protections in Place Local Agency County legislation/regulation State Agency State Good Samaritan Laws State Legislation specifically protecting volunteer health professionals Purchased private insurance Federal Volunteer Protection Act Workers Compensation Other (please specify)	Unit Profile Data Element
	Describe the Jurisdiction that your MRC unit will cover?	New Unit Interview Question
	Describe the public health and emergency preparedness/response mission and focus of your mrc unit?	New Unit Interview Question
	Describe the goals and objectives of your MRC unit?	New Unit Interview Question
	Describe your MRC unit’s affiliations and partnerships with other local or state governmental or non-governmental organizations and agencies?	New Unit Interview Question
	Describe how your MRC unit is integrated with the local and state emergency plans (ESF-8) for your jurisdiction?	New Unit Interview Question
	Describe the organization structure of your MRC unit?	New Unit Interview Question
	Describe the composition of your MRC unit?	New Unit Interview Question
	Describe the recruitment plans of your unit?	New Unit Interview Question
	Describe your MRC unit’s plans for screening and selecting members and staff, including the verification of professional credentials?	New Unit Interview Question
	Describe your MRC unit’s administrative plans and procedures?	New Unit Interview Question
	Describe how your MRC unit has participated in the MRC “network”?	New Unit Interview Question

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0302. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer