MEDICAL OFFICES AND CLINICS PANDEMIC INFLUENZA PLANNING CHECKLIST

Planning for pandemic influenza is critical for ensuring a sustainable healthcare response. The Department 

of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) have 

developed the following checklist to help medical offices and ambulatory clinics assess and improve their 

preparedness for responding to pandemic influenza. This checklist is modeled after a pandemic preparedness 

checklist for hospitals and should be used in conjunction with guidance on healthcare preparedness planning in Supplement 3 

of the HHS Pandemic Influenza Plan. Many of the issues included in the checklist are also relevant to other outpatient settings 

that provide episodic and chronic healthcare services (e.g., dental, podiatric, and chiropractic offices, ambulatory surgery 

centers, hemodialysis centers). Given the variety of healthcare settings, individual medical offices and clinics may need to 

adapt this checklist to meet their unique needs. Further information can be found at www.pandemicflu.gov.

This checklist identifies key areas for pandemic influenza planning. Medical offices and clinics can use this tool to identify 

the strengths and weaknesses of current planning efforts. Links to websites with information are provided throughout the 

document. However, actively seeking information that is available locally or at the state level will be necessary to complete 

the development of the plan. Also, for some elements of the plan (e.g., education and training programs), information may 

not be immediately available and it will be necessary to monitor selected websites for new and updated information. 

1. Structure for planning and decision making.

Pandemic influenza has been incorporated into emergency management planning for the organization.

A planning committee1 has been created to specifically address pandemic influenza preparedness for the 

medical office or clinic.

A person has been assigned responsibility for coordinating preparedness planning for the practice or 

organization (hereafter referred to as the pandemic influenza response coordinator).

(Insert name, title and contact information) 

Members of the planning committee include the following: (Insert below or attach list with name, title 

and contact information for each) 

Administration: 

Medical staff: 

Nursing: 

Reception personnel: 

Environmental services (if applicable): 

Clinic laboratory personnel (if applicable): 

Other member(s): 

A point of contact (e.g., person assigned infection control responsibility for the organization or an outside 

consultant2) for questions/consultation on infection control measures to prevent transmission of pandemic 

influenza has been identified. (Insert name, title, and contact information) 

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1. The committee could be very small (e.g., two or three staff members) or very large, depending on the size and needs of the organization. 

2. Formal memorandum of understanding or contract may be needed if an outside consultant is used.

March 6, 2006

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2. Development of a written pandemic influenza plan. 

Copies of relevant sections of the Department of Health and Human Services Pandemic Influenza Plan 

have been obtained from www.hhs.gov/pandemicflu/plan; copies of available state pandemic plans 

also should be obtained.

A written plan has been completed or is in progress that includes the elements listed in #3 below.

The plan describes the organizational structure that will be used to operationalize (i.e., lines of 

authority) the plan.

The plan incorporates and compliments the community response plan.

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3. Elements of an influenza pandemic plan.

A plan is in place for surveillance and detection of pandemic influenza in the population served.

 Responsibility has been assigned for monitoring public health advisories (federal and state) and 

informing members of the pandemic influenza planning committee and/or the pandemic influenza 

response coordinator when pandemic influenza is in the United States and when it is nearing the 

geographic area (e.g., state and/or city). (For more information, see www.cdc.gov/flu/weekly/

fluactivity.htm) (Insert name, title and contact information)

 

 A system has been created to monitor and review influenza activity in patients cared for by clinical 

staff (i.e., weekly or daily number of patients calling or presenting to the office or clinic with 

influenza-like illness) and among medical office or clinic staff. (For more information see 

www.cdc.gov/flu/professionals/diagnosis/) (Monitoring for seasonal influenza activity is performed 

to ensure that the monitoring system for pandemic influenza will be effective and will ensure that 

organizations can detect stressors that may affect organizational capacity, such as staffing and supply 

needs, and hospital and emergency department capacity [and supply needs] during a pandemic) 

 A system is in place to report unusual cases of influenza-like illness and influenza to the local or state 

health department. (For more information see www.hhs.gov/pandemicflu/plan/sup1.html#outpat

and www.hhs.gov/pandemicflu/plan/sup5.html#nov)

A communication plan has been developed.

 Key public health points of contact for pandemic influenza have been identified and arrangements 

have been made for telephone, facsimile, or e-mail messaging.

 Local health department contact: (Insert name, title and contact information) 

 State health department contact: (Insert name, title and contact information) 

 The office or clinic’s point person for external communication has been assigned. (Insert name, title 

and contact information) 

 (Having one person who speaks with the health department, and if necessary, media, local 

politicians, etc., will help ensure consistent communication is provided by the organization)

 A list has been created of healthcare entities and their points of contact (e.g., local hospitals/health 

facilities, home health care agencies, social service agencies, emergency medical services, commercial 

and clinical laboratories, relevant community organizations [including those involved with disaster 

preparedness]) with whom the medical office or clinic anticipates that it will be necessary to maintain 

communication and coordination of care during a pandemic. (Attach or insert location of contact list) 

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3. Elements of an influenza pandemic plan. (continued)

 The pandemic response coordinator has contacted local or regional pandemic influenza planning 

groups to obtain information on communication and coordination plans, including notification when 

updated plans are created. (For more information on state and local planning, see www.hhs.gov/

pandemicflu/plan/part2.html#overview)

 A list or database has been created with contact information on patients who have regularlyscheduled visits and may need to be contacted during a pandemic for purposes of rescheduling office 

visits or assigning them to another point of care. (Insert location of list/database) 

 

 

A plan is in place to provide an education and training program to ensure that all personnel 

understand the implications of, and control measures for, pandemic influenza.

 A person has been designated to coordinate education and training (e.g., identify and facilitate 

access to education and training programs, maintain a record of attendance at education and training 

programs). (Insert name, title and contact information) 

 Current and potential opportunities for long-distance (e.g., web-based) and local (e.g., health 

department or hospital sponsored programs, programs offered by professional organizations or 

federal agencies) education of medical and nursing personnel have been identified. 

(http://www.cdc.gov/flu/professionals/training/)

 Language and reading-level appropriate materials on pandemic influenza (e.g., available through 

state and federal public health agencies and professional organizations) appropriate for professional, 

allied and support personnel have been identified and a plan is in place for obtaining these materials. 

(For more information see www.cdc.gov/flu/professionals/patiented.htm) 

 Education and training includes information on infection control measures to prevent the spread of 

pandemic influenza. www.hhs.gov/pandemicflu/plan/sup4.html

Informational materials for patients on pandemic influenza that are language and reading-level 

appropriate for the population being served have been identified, and a plan is in place to obtain 

these materials. (For more information see www.cdc.gov/flu/professionals/patiented.htm)

 The roles of medical and nursing personnel in providing health care guidance for patients with 

pandemic influenza have been established.

A plan for triage and management of patients during a pandemic has been developed.

 A system is in place for phone (and e-mail, where appropriate) triage of patients to determine who 

requires a medical evaluation, to limit office visits to those that are medically necessary.

 Plans have been developed to manage patient care at the height of the pandemic including the 

following possibilities:

 • Temporarily canceling non-essential medical visits (e.g., annual physicals).

 • Designating separate blocks of time for non-influenza and influenza-related patient care.

 Local plans and criteria for the disposition of patients following a medical evaluation (e.g., 

hospitalization, home health care services, self- or family-based care at home) have been discussed 

with local hospital and health care agencies and local health department. (Flexibility will be 

necessary based on hospital bed capacity)

An infection control plan is in place and includes the following: (For information on infection 

control recommendations for pandemic influenza see www.hhs.gov/pandemicflu/plan/sup4.html)

 A specific waiting room location has been designated for patients with symptoms of pandemic 

influenza that is segregated from other patients awaiting care. (This may not be feasible in very 

small waiting rooms, in which case the emphasis may be on use of masks as noted below) 

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3. Elements of an influenza pandemic plan. (continued)

 A plan for implementing Respiratory Hygiene/Cough Etiquette is in place. (For more information 

see www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm)

 • Signage (language appropriate) directing patients and those accompanying them to notify reception 

personnel if they have symptoms of pandemic influenza has been developed or a source of signage 

(e.g., CDC website above) has been identified.

 • Signage (language appropriate) on Respiratory Hygiene/Cough Etiquette instructing symptomatic 

persons to use tissues to cover their cough to contain respiratory secretions and perform hand 

hygiene has been developed or a source of signage (e.g., CDC website above) has been identified.

 • The plan includes distributing masks to symptomatic patients who are able to wear them (adult and 

pediatric sizes should be available), providing facial tissues, receptacles for their disposal and hand 

hygiene materials in waiting areas and examination rooms.

 • Implementation of Respiratory Hygiene/Cough Etiquette has been exercised during seasons when 

influenza and other respiratory viruses (e.g., respiratory syncytial virus, parainfluenza virus) are 

circulating in communities.

 • If patients with pandemic influenza will be evaluated in the same location as patients without an 

influenza-like illness, separate examination rooms have been designated for evaluation of patients 

with symptoms of pandemic influenza.

 • A policy is in place that requires healthcare personnel to use Standard (www.cdc.gov/ncidod/

dhqp/gl_isolation_standard.html) and Droplet Precautions (i.e., mask for close contact) (www.

cdc.gov/ncidod/dhqp/gl_isolation_droplet.html) with symptomatic patients. 

 • The policy includes protection of reception and triage personnel at initial points of patient 

encounter.

A vaccine and antiviral use plan has been developed.

 Websites where current federal and/or state health department recommendations for the use and 

availability of pandemic influenza vaccines and antiviral medications have been identified. (for more 

information see www.hhs.gov/pandemicflu/plan/sup6.html)

 An estimate of the number of personnel and patients who would be targeted as first and second 

priority for receipt of pandemic influenza vaccine or antiviral prophylaxis, based on HHS guidance 

for use, has been developed. (www.dhhs.gov/nvpo/pandemicplan/annex6.pdf) (This estimate 

can be used for considering which patients may need to be notified first about vaccine or antiviral 

availability, anticipating staffing requirements for distribution of vaccines and antivirals, and for 

procurement purposes)

An occupational health plan has been developed and includes the following:

 A liberal/non-punitive sick leave policy for managing personnel who have symptoms of or 

documented illness with pandemic influenza.

 The policy considers:

 • The handling of staff who become ill at work.

 • When personnel may return to work after recovering from pandemic influenza.

 • When personnel who are symptomatic, but well enough to work, will be permitted to continue 

working.

 • Personnel who need to care for their ill family members.

 A system for evaluating symptomatic personnel before they report for duty and tested during a nonpandemic influenza period. 

 Mental health and faith-based resources that are available to provide counseling to personnel during 

a pandemic. 

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3. Elements of an influenza pandemic plan. (continued)

 The management of personnel who are at increased risk for influenza complications (e.g., pregnant 

women, immunocompromised healthcare workers) by placing them on administrative leave or 

altering their work location. 

 The ability to monitor seasonal influenza vaccination of healthcare personnel.

 The offer of annual influenza vaccine to medical office or clinic personnel. 

Issues related to surge capacity (i.e., dealing with an influx of patients and staff and supply 

shortages) during a pandemic have been addressed. (For more information see www.hhs.gov/

pandemicflu/plan/sup3.html#surge)

 Plans for managing a staffing shortage within the organization due to illness in personnel or their 

family members have been addressed.

 Staff have been encouraged to develop their own family care plans for the care of dependent minors 

and seniors in the event community containment measures (e.g., “snow days,” school closures) 

are implemented. (www.pandemicflu.gov/planguide/checklist.html; www.pandemicflu.gov/

planguide/familyhealthinfo.html)

 The minimum number and categories of personnel necessary to keep the office/clinic open on a 

given day have been determined.

 Plans for either closing the office/clinic or recruiting temporary personnel during a staffing crisis 

have been addressed.

 Anticipated consumable resource needs (e.g., masks, gloves, hand hygiene products, medical 

supplies) have been estimated.

 A primary plan and contingency plan to address supply shortages have been developed and each 

details procedures for acquisition of supplies through normal channels, as well as requesting 

resources when normal channel resources have been exhausted.

 Plans include stockpiling at least a week’s supply of consumable resources, including all necessary 

medical supplies, when there is evidence that pandemic influenza has reached the United States.

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