Spreadsheet: 325bb441-11a9-4763-a818-1f62fca29d29
Sheet: Example Workbook

 | ([NAME]. here)             Hospital Name: |  | Hospital Contact: |  |  |  | Contact Information:       Phone:       [NAME]:
 | Hosptial Preparedness Program Activities:
 | Capability  - Basic overview of Resource Element within Capability | HPP Capability Reference                                                                                                                                                                                                                                                                                                                                   C = Capability                                                                                                               F= Function                                                                                 Link to Healthcare Preparedness Capabilities:                           http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/capabilities.pdf | Examples of program activity that will meet the Resource Element.                                                             (Individual facility activity may differ) | Type of Program Activity                                                                                               (Planning, Equipment, Training, Exercises, Travel) | All activities listed as "Required" MUST be completed in order to receive HPP funding. | Example of Program Expenditure and Process when submitting to Colorado Rural Health Center for Reimbursment                                             (Equipment purchases will require signed MOA provided by CDPHE) | Equipment/ Staff Time/Activity Narrative                                                                            NOTE: A brief narrative must be completed for ALL Required or Selected Resource Elements including those without funding requests. | Requested Allocation of HPP Funds
 | Healthcare System Preparedness |  |  |  |  |  |  | Estimated Allocation of HPP Funds Here
1 | Develop [NAME] or Sustain Healthcare Coalitions | HPP C1, F1 | Participate in a minimum of three Healthcare Coalition meetings within your "region or defined area": | Planning | Required | Provide documentation illistrating attendance in Healthcare Coalition meetings.  (Must include meeting minutes, agenda & list of attendees by facility affiliation.) | Example 1: Travel expense reimbursement funds needed for staff attending healthcare coalition meetings.  (Milage, staff time, etc)                                                                                                                         OR                                                                                                                                    Example 2: No funding needed to complete this activity | Example 1: $1,688.00                                                                                                         OR                                                                                  Example 2: $0.00
2 | NIMS/ICS -100% compliant | HPP C1, F5 | If not already100% compliant identify steps toward compliance (NIMS Compliance Work Plan) and document progress.  100% compliance is expected to receive current grant period funding. | Planning/ Training | Required | Provide documentation illustrating costs related to NIMS training for hospital staff; Costs for contractor to work on hospital Emergency Operations Plan; costs for staff travel & time related to completing NIMS/ICS training courses. | No funding needed.  New staff training requirement is integrated in facility procedures.  No costs associated. | 0
 | Information Sharing |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
3 | Bed Tracking - Hospital shall be able to report available HavBED availability into EMSystem | HPP C1 F2, F4                                                                                              HPP C1, F1                                                                             HPP C10 | Hospital will participate in annual HHS mandatory HavBED drill using EMSystem. Hospitals must report their HavBED availability within 4 hours of the EMSystem Event Notification | Planning/ Training | Required | Provide a"Communications [NAME]" illustrating drill participation. | No funding needed for this activity.  Staff time associated minimal and cost negligible or already associated with staff duties. | 0
4 | Interoperable Communication Systems Drills -Develop, refine, and sustain redundant, interoperable communication systems | HPP C1, F2, F6                                                                            HPP C6, F1, F2                                                                               HPP C10, F3 | Hospital will conduct 4 comms drills (minimum of two EMSystem and two 800mhz radio drills) and provide a"Communications [NAME]" demonstrating vertical communication with local, state, and/or Federal incident management and ESF #8, and/or horizontal communication with critical healthcare response partners in the community. Drills are encouraged to be  in coordination with health care coalition planning and exercises or real events taking place at the regional/local level. | Planning | Required | Provide a"Communications [NAME]" illustrating drill participation. | Staff time and/or associated cost reimbursement needed to cover participation in drill activites.                                                                                                                             4 staff @ $50  1 hr = $200 | 200
5 | Exercise/Real Event -  Implementation and coordination - To address gaps, use HSEEP, horizontal and vertical coord. | HPP C1, C2, [NAME], C5, C6, [NAME], C14, C15 | Conduct exercises; participate in local, Regional, or statewide exercise events.  Exercises must be regional or coordinated through your Health Care Coalition, FSE and HSEEP compliant. | Exercise |  | Provide HSEEP compliant AAR & documentation illustrating costs related to, contractor costs, staff time and travel to conduct, evaluate, or participate in exercise events; Costs for equipment and supplies needed for exercises. | Exercise Costs associated with planning, staff time, equipment usage, etc.                                                                                                 10 staff X 4 hrs X $50 hr = $2000                                                                           Equipment consumed = $200                                                                                                                  Food/Etc. = $600 | 2800
6 | Exercise/Real Event  - Evaluation - HSEEP, After [NAME], Improvement Plans, use findings to revise processes | HPP C1, C2, [NAME], C5, C6, [NAME], C14, C15 | Coordinate post-exercise assessment and after-action plan development; revise EOP base on findings from exercises | Exercise |  | Provide documentation illustrating costs related to contractor costs,staff time and travel to conduct, evaluate, or participate in exercise events; Costs for equipment and supplies needed for exercises. | No funding requested as exercise evaluators will be voluntary. | 0
7 | Exercise - Exercise and evaluation training to improve exercise coordination, implementation, and evaluation | HPP C1 C2, [NAME], C5, C6, [NAME], C14, C15 | Provide or attend training courses to improve the hospital ability to conduct and evaluate exercise events such as a Master exercise practicioner course found at:  [NAME] | [NAME] |  | Provide documentation illustrating costs related to hospital staff time, contractor costs and travel to participate in exercise evaluation training activities. | No exercise evaluation training planned for this grant cycle. | 0
 | Healthcare System Recovery |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
8 | COOP/Recovery - Plans, priorities, resupply, notification, return to normal operations | HPP C1 F2, F5                                                                      HPP C2 F2 | Development of continuity and recovery plans and processes; assessment of recovery needs at hospital | Planning |  | Provide documentation illustrating costs for a contractor and staff time  to develop a COOP plan for the hospital. | No funding requested as COOP plan tested/updated  4/1/2013. | 0
 | Emergency Operations Coordination |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
9 | Incident Management - Incident information sharing, facility status reports, expected activations, communication with public, partners, emergency management | HPP C1, F1                                                                                                            HPP C3, F1, F2, F3, F4                                                                      HPP C6, F1, F2 | Development of processes to collect, aggregate, and share facility specific incident status information with hospital staff, patients and families, Coalition partners, and emergency management | Planning |  | Provide documentation illustrating costs related to emergency operations plan development for hospital, to include status reporting and information sharing in coordination with coalition partners. | No funding requested as Emergency Operations Planning will be discussed during healthcare coalition meetings.  Internal facility emergency operation plans have been tested/updated. | 0
10 | Resource Coordination - Managing and resupplying resource caches, inventory, tracking of used supplies | HPP C1, F4                                                                                                                   HPP C3, F2                                                                                                                          HPP C5, F1                                                                                   HPP C10, [NAME]HPP C14, F1, F2 | Development of processes to track the use of disaster supplies that are utilized during a response | Planning |  | Provide documentation illustrating costs related to development of inventory management plans for disaster equipment in coordination with healthcare coalition partners. | No funding requested as emergncy operations supply have been restocked and inventoried. | 0
11 | Inventory management System - to track and record available and shared assets | HPP C1, F3, F4                                                                                  HPP C3, F3 | Develop a system to tag and track disaster response equipment at hospital | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of an inventory management system, to be used solely for the identification, tracking, and resupply of disaster response equipment in coordination with healthcare coalition partners. | No funding requested as system already in place and maintained internally.  Discussion of how to share this information with partners will be discussed in Healthcare Coalition meetings. | 0
12 | Command Center Training - Ensure hospital staff have been trained on the operation and management of hospital command center | HPP C1, [NAME], F1, F2, F3, F4 | Provide training courses for staff who will fulfill command center roles and responsibilities | Training |  | Provide documentation illustrating costs for staff time and other costs related to command center skills development, such as a trainer, supplies, photocopies of manuals, etc. in coordination with healthcare coalition partners. | No funding requested as command center training not identified as a priority funding item for this grant cycle. | 0
13 | Command Center Equipment - Ensure adequacy of supplies and equipment to fulfill hospital command center functions | HPP C1, F5                                                                                     HPP C3, F1, F2, F3, F4 | The hospital will maintain a functioning command center that serves as the information hub and incident management location for the facility. | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of HICS vests, printer, laptop, dry erase board, signage, HICS binders, monitors, storage cabinets, etc. | 800MHz radios (Basestation & 2 Handhelds) needed for EOC | 6000
 | Fatality Management |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
14 | Fatality Plan - human remains surge plans - Storage, resources, transport, coord. with EM, legal, cultural | HPP C1, F2, F6                                                                              HPP C5, F1 | Hospital will develop a mass fatality management plan that includes commonly accepted plan elements | Planning |  | Provide documentation illustrating costs to hire a contractor if needed to develop mass fatality plan in coordination with coroner and healthcare coalition partners. | No funding requested as our fatality plan is currently up to date. | 0
15 | Mortuary storage equipment and supplies - Assets needed to support anticipated death estimates | HPP C1, F2, F6                                                                             HPP C5, F1 | Based on anticipated death estimates, and gap with existing supplies, hospital will purchase equipment to support appropriate treatment of decedents | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of bioseals, body bags, morgue packs, personal possession bags, etc. | No funding requested as this has not been identified as a priority by our facility. | 0
16 | Fatality Management Training | HPP C1, F5, F6                                                                                 HPP C5, F1 | Hospitals provide fatality management training for staff. ([NAME], behavioral health, etc.) | Training |  | Provide documentation illustrating costs to hire contractor, staff time. | No funding requested as this has not been identified as a priority by our facility.
17 | Bed Tracking Systems - Maintain and improve EMSystems reporting capability at hospital | HPP C1, F2, F4                                                                                             HPP C6 F1                                                                                   HPP C10 | Hospital will utilize EMSystem to update and monitor bed availabilty and hospital status | Planning/Training |  | Provide documentation illustrating costs for staff time. | No funding requested as our staff is fully trained and efficient in using the system both daily and in emergency situations. | 0
18 | Interoperable communications plans - Between EOC, Hospital, on-scene, incident management, redundancy | HPP C1, F2, F6                                                                             HPP C6, F1, F2 | Hospital will develop/refine emergency communications or CHECS plans to address the use of social media in coordination with health care coalition. | Planning |  | Provide documentation illustrating costs to develop plan. | No funding requested as these communication plans are fully tested during annual/internal exercises/drills. | 0
19 | Interoperable Communication Equipment - EOC, Hospital, on-scene, incident management, redundancy | HPP C1, F2, F6                                                                                 HPP C6, F1, [NAME], F3 | Hospital will purchase equipment to replacing or enhancing Interoperable Communication Systems | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of Interoperable Communication Systems | 12 two-way radios for use during incidents/exercises. | 5000
20 | Communication training - based on identified needs, train on primary and redundant systems, info exchange protocols | HPP C1, F3, F4                                                                        HPP C3, F2                                                                              HPP C6, F1, F2 | Hospital will ensure that any staff who may use redundant communication systems have been provided adequate training on systems. | Training |  | Provide documentation illustrating costs for contractor or staff to train on the use of various communication methods. | No funding requested as training facilitated through exercises/drills internally.  Also a train the trainer program is offered for new staff. | 0
 | Medical Surge |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
21 | Surge Capacity Planning -Maximize surge capacity, surge assessment, clearing of beds, available resources, alternate care sites | HPP C1,F3, F4, F6                                                    HPP C10, F1, F2, F3, F4, F5 | Hospital will conduct pre-surge assessment to determine existing surge capacity, resources, and staffing, and will develop process to clear (decompress) beds during a surge event. Hospital will identify locally available resources (equipment, staff, beds) that may be available to assist in coordination with healthcare coalition | Planning |  | Provide documentation illustrating costs related to development/ refinement of medical surge plan elements. | No funding requested as surge capacity planning/assessment takes place during annual exercises, drills, real time events & healthcare coaltion meetings. | 0
22 | Surge Capacity Planning -                                                 Patient transport assistance - for needs above routine transfers, address medical and legal issues, Fed. Support | HPP C1, F3, F4, F6                                                                      HPP C10, F1, F2, F3, F4, F5 | Hospital will coordinate with health care Coalition, jurisdiction, and EMS partners to pre-identify transportation options that may be available to support patient transportation needs | Planning |  | Provide documentation illustrating costs related to development/ refinement of medical surge plan elements. | No funding requested as surge capacity planning/assessment takes place during annual exercises, drills, real time events & healthcare coaltion meetings. | 0
23 | Surge Equipment - Specialty equipment to increase medical surge capacity and capability - tents, supplies, special equipment | HPP C1, F3, F4                                                                     HPP C10, F3 | Based on Health Care Coalition HVA, hospital will purchase surge supplies to support identified threats | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of tents, medical equipment, patient tracking handhelds, patient care supplies, specialty equipment (pediatric, burn, trauma). | No funding requested as (specify capability) identified priority for this grant cycle. | 0
24 | [NAME] to maximize medical surge capability | HPP C1, F3, F4, F6                                                                    HPP C10 | Hospital will conduct training courses for staff to familiarize them with medical surge equipment | Training |  | Provide documentation illustrating costs for attendance at training events, hosting training events, contractor or staff time. | No funding requested as surge capacity planning/assessment takes place during annual exercises, drills, real time events & healthcare coaltion meetings. | 0
25 | Mobile Medical - Plans for mobile medical assets for surge operations - type of care, movement, resupply, staff, training, etc. | HPP C1, F2, F4                                                                            HPP C10, F3 | Hospital will develop protocols for use of mobile medical assests and protocols to allow other facilities to access | Planning |  | Provide documentation illustrating costs related to development of mobile asset protocols. | No funding requested as these protocols are already in place and are routine tested. | 0
26 | Mobile Medical Assets -  equipment, trailers, etc. | HPP C1, F2, F4                                                                             HPP C10, F3 | Hospital may purchase mobile medical assets for off site triage and treatment for patients | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of mobile medical assests. | No funding requested as (specify capability) identified priority for this grant cycle. | 0
27 | Decontamination Plans - To ensure that processes are in place to provide decontamination services | HPP C1, F2, F3, F4, F6                                                               HPP C10, F3 | Hospital will develop or update plans, protocols, and equipment maintenance processes for decon for ambulatory and stretcher bound patients | Planning |  | Provide documentation illustrating costs related to plan development, contractor or staff time. | No funding requested as these protocols are already in place and are routine tested. | 0
28 | Decontamination Assets - Strategically locate decontamination assets in coodination with decontamination plan. | HPP C1, F2, F3, F4                                                           HPP C10, F3 | Hospital will purchase equipment to expand decon capability to accept stretcher bound patients. | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of shelter, sponges, buckets, PAPR, cooling vests, boots, portable shower, water containment, patient gowns, hoses, etc. | No funding requested as our facility has sufficient supplies for handling decontamination. | 0
29 | Decontamination training - to support sustainment of decontamination capacity, training on equipment | HPP C1 F2, F3, F4, F6                                                              HPP C10, F3 | Hospital will conduct refresher trainings for identified decon team members | Training |  | Provide documentation illustrating costs for attendance at training events, hosting training events, contractor, staff time. | No funding requested as decontamination planning/assessment takes place during annual exercises, drills, real time events & healthcare coaltion meetings. | 0
30 | Evacuation and Sheltering plans - coordinate with health care coalition to identify resources, information sharing | HPP C1, F2, F3, F4, F6                                                             HPP C10, F5 | Hospital will refine evacuation plan to include health care Coalition assistance that may be available | Planning |  | Provide documentation illustrating costs related to plan development, contrator, staff time. | No funding requested as decontamination planning/assessment takes place during annual exercises, drills, real time events & healthcare coaltion meetings. | 0
31 | Evacuation Equipment - Specialized equipment needed to evacuate patients | HPP C1, F2, F3, F4                                                                   HPP C10, F3 | Hospital will purchase additional evacuation equipment due to an expansion of patient care units | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of evacuation equipment. | MedSleds 5 X $1000 | 5000
 | Responder Safety and Health |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
32 | Occupational Safety and Health Plan | HPP C1, F2, F3, F4, F6                                                              HPP C14, F1, F2 | Hospital will Develop, refine, and sustain processes to equip, train, and provide other resources needed to ensure healthcare workers at the highest risk for adverse exposure, illness, and injury are adequately  protected from all hazards during response and recovery operations. | Planning |  | Provide documentation illustrating costs related to plan development, contractor, staff time. | No funding requested as these plans are already in place as part of annual facility procedures | 0
33 | PPE for healthcare workers -  meets nationally recognized standards (OSHA, CDC, FDA) | HPP C1, F2, F3, F4                                                                  HPP C14, F2 | Hospital will assess PPE needs, develop use protocols, and purchase PPE adequate to meet identified need for facility in coordination with health care coalition | Equipment |  | Provide invoices and confirmation of receipt involving  purchase of PPE Equipment. | No funding requested as our current PPE is fully stocked for our needs. | 0
34 | PPE training - Training on supplemental or cached supplies | HPP C1, F2, F3, F4, F6                                                       HPP C14, F1, F2 | Hospital will conduct yearly PPE training for staff that may be involved in medical surge responses | Training |  | Provide documentation illustrating costs for attendance at training events, hosting training events, contractor, staff time. | No funding requested as training already part of annual staff training. | 0
 | [NAME] |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
35 | [NAME] hospital will utilize volunteers during a response event | HPP C1, F2, F3, F4, F6                                                          HPP C15, F1, F2, F3, F4 | Hospital will develop a volunteer response management plan to include hospital volunteers, medical reserve core or other medical volunteer groups. | Planning |  | Provide documentation illustrating costs related to plan development. | No funding requested as this planning is already part of facility EOP and is reviewed annually. | 0
36 | [NAME] hospital will orient and train pre-identified volunteers groups | HPP C1, F2, F3, F4, F5, F6                                                      HPP C15, F1, F2, F3, F4 | Hospitals will conduct training to orient volunteers  to orient them to facility equipment and procedures. | Training |  | Provide documentation illustrating costs for attendance at training events, hosting training events,contractor, staff time. | No funding requested as this planning is already part of facility EOP and is reviewed annually. | 0
 |  |  |  |  |  |  | Enter identified needs, proposed activity, and type of equipment to be purchased in this section, see example in guidance. | Enter line item budget amounts here.
 |  |  |  |  |  |  | Total Funding Amount