**TEMPLATE 5. INCIDENT-SPECIFIC PUBLIC HEALTH PREPAREDNESS**

The following template can be used to help determine your health
department's level of preparedness to respond to direct and indirect
public health threats associated with specific types of emergencies and
disasters. Incidents are divided into two categories: Natural and
Technological/Man-Made\*. The incidents listed in this template are only
examples and should not be considered all-inclusive. Blank space is
provided at the end of the template to allow users to list additional
incidents that may affect their area(s). Use the grid to evaluate your
health department's ability to respond to specific incidents by placing
an "X" next to each incident under the ranking that most accurately
represents your health department's level of preparedness to respond to
that particular incident. This evaluation should be based on state and
local public health emergency preparedness guidance developed by CDC and
the doctrine, concepts, principles, terminology, and organizational
processes in the *National Response Plan (NRP)* and *National Incident
Management System (NIMS)*. When completed, this template can be used to
prioritize preparedness activities and can identify those incidents for
which additional (state, federal, etc.) response assistance would be
required. This template should be updated as new preparedness activities
are undertaken.

\* *Technological/Man-Made incidents can be intentional or
unintentional, including acts of terrorism.*

+---------------------------+-------+-------+-------+-------+-------+
|                           | *     |       |       |       |       |
|                           | *Rank |       |       |       |       |
|                           | ing** |       |       |       |       |
+===========================+=======+=======+=======+=======+=======+
|                           | *     |       | **    |       |       |
|                           | *Most |       | Least |       |       |
|                           | Prepa |       | Prepa |       |       |
|                           | red** |       | red** |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| **Type of Incident**      | **4** | **3** | **2** | **1** | **    |
|                           |       |       |       |       | N/A** |
+---------------------------+-------+-------+-------+-------+-------+
| > **Natural**             |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Avalanche               |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Drought                 |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Earthquake              |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Extreme cold            |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Extreme heat            |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Fire/Wildfire           |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Flood                   |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Hurricane/tropical      |       |       |       |       |       |
| > storm                   |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Infectious disease      |       |       |       |       |       |
| > outbreak                |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Landslide/mudflow       |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Snow/blizzard           |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Thunderstorm/lightning  |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Tornado                 |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Tsunami                 |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Volcano                 |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > *                       |       |       |       |       |       |
| *Technological/Man-made** |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Airplane crash          |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Biological release      |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Building/structural     |       |       |       |       |       |
| > collapse                |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Chemical/hazardous      |       |       |       |       |       |
| > substance release       |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Civil                   |       |       |       |       |       |
| > unrest/disobedience     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Critical infrastructure |       |       |       |       |       |
| > failure:                |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Telecommunications      |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Electrical power        |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Gas and oil             |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Transportation          |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Water supply            |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Sanitation              |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Explosion               |       |       |       |       |       |
| > (conventional)          |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Maritime                |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Mass immigration        |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Mass public gathering   |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Mine collapse/explosion |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Radiological/nuclear    |       |       |       |       |       |
| > release                 |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > Train derailment        |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > **Other Incident(s)**   |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+
| > [     ]{.underline}     |       |       |       |       |       |
+---------------------------+-------+-------+-------+-------+-------+