Roadmap to Ready Application

Transcription

1 Roadmap to Ready Application The National Association of County and City Health Officials (NACCHO) has developed the Roadmap to Ready program to: Provide an overview of the public health preparedness landscape, including essential federal guidance, policies and regulations, and partners to engage; Deliver a curriculum to help coordinators more rapidly adjust to their new roles through the provision of specifically tailored resources and individual development plans; and Establish a network of local emergency preparedness coordinators through the assembly of teams led by experienced preparedness mentors and the development of collaborative learning and sharing platforms With these goals in mind, NACCHO is currently accepting applications for new preparedness coordinators and preparedness mentors to participate in the Roadmap to Ready Program which includes a one-day workshop at the 2016 Preparedness Summit on Monday, April 18, 2016 located at the Dallas Hilton Anatole in Dallas, TX. Applications will be accepted through December 15, Please note that completing this application does not guarantee you a spot in the workshop. Applicants will be notified of selection status in January We encourage you to distribute this survey link to other individuals who might be interested in participating as either new preparedness coordinators or experienced preparedness mentors. For any questions about the application process, please contact preparedness@naccho.org. For more information on the Roadmap to Ready Program, visit Click on the red button below to begin the application. You may use the red buttons at the bottom of each page to navigate through the application and return to prior questions. When you reach the final page of the survey, please be sure to submit your responses. Responses are saved each time you navigate to a new page using the red buttons. You may return to the application at any time to complete the application if you do not finish. Please note that you should use the same electronic device when making additional edits if you plan to complete the application at a later time.

2 Please fill out the following items: First Name Last Name Phone Number Organization/Agency Position Title Agency Address City State Zip Code Any applicable credentials that you would like to have listed on materials (MPH, BA, MS, RN, etc.) List any relevant certifications or credentials (100 character max)

3 Select Time Zone: Atlantic Standard Time (AST) Eastern Standard Time (EST) Central Standard Time (CST) Mountain Standard Time (MST) Pacific Standard Time (PST) Alaskan Standard Time (AKST) Hawaii-Aleutian Standard Time (HST) Samoa Standard time (UTC-11) Chamorro Standard Time (UTC+10) Other Select Jurisdiction Population Size: 0-10,000 10,001-50,000 50, , , , ,001-1,000,000 More than 1,000,000 Select HHS Region (see map): Other Please select your participant type: New Preparedness Coordinator Preparedness Mentor Preparedness Mentor Application Important Information about Preparedness Mentor Responsibilities Volunteering as a Preparedness Mentor is a great opportunity to assist NACCHO and the local public health preparedness community. The process allows you to interact with other professionals in your field and to share your expertise and knowledge with those new to the

4 preparedness field. Additionally, you will also have the opportunity to network with other experienced mentors and will be given access to all developed program resources. Mentors should ideally have at least 5 years of public health preparedness experience, though exceptions can be made for highly qualified applicants. Mentors will oversee 2-4 new preparedness coordinators on their mentor teams. These coordinators will all have less than 2 years of experience in their roles. Mentors will be required to commit to the following activities: Provide mentoring and guidance for up to four new preparedness coordinators on their teams Attend a mentor orientation webinar prior to the workshop Attend a mentor training call/webinar prior to the workshop Prepare workshop content prior to the workshop Facilitate team activities during the workshop Coordinate mentor team learning and sharing opportunities to address challenges faced by program participants Provide guidance and feedback to mentor team members as needed for up to six months following the Preparedness Summit Complete programmatic surveys throughout the course of the program Expected total time commitment is approximately 30 hours over the course of the year: 1 hour orientation webinar 1 hour mentoring training 5 hours of prep work prior to the Summit 8 hour all-day workshop 4 hours for learning and sharing opportunities 8 hours of technical assistance and guidance for new preparedness coordinators on your team (estimated) 2 hours of miscellaneous program activities Note: there will also be optional networking event(s) during the week of the Preparedness Summit. Please confirm with your supervisor that you will be permitted to participate in all of the above activities before completing this survey. Scholarship Information: Preparedness mentors may also apply for a scholarship to cover a portion of their Preparedness Summit expenses. Scholarships may cover a portion of the conference registration, travel, and lodging expenses. Any expenses beyond the awarded scholarship amount will be the responsibility of the mentor. Please note that there are a limited number of scholarships

5 available, and completing the application does not guarantee that you will be awarded a scholarship. For more specific details regarding the Roadmap to Ready Program visit:

6 Note on the Preparedness Mentor Selection Process Filling out this survey is not a guarantee that you will serve as a Preparedness Mentor for Roadmap to Ready. The number of available mentor slots is determined by the number of new preparedness coordinator applicants. Mentors will be selected from the list of interested individuals based on the following criteria: 1. Agreement to all mentor responsibilities; 2. Previous preparedness coordinator experience, particularly on the local level; (at least 5 years of cumulative preparedness experience preferred, though not required) 3. Leadership experience; 4. Current position and its relationship to public health preparedness; 5. Subject matter expertise or knowledge on session topics; 6. Involvement in current and past NACCHO activities; 7. Diversity of geography and professional background. NACCHO has sole discretion regarding mentor selections and mentor team assignments. Have you participated in this program before as a mentor, participant, or faculty member? Mentor Participant Faculty Member None of the Above Please indicate which areas you have professional experience. (check all that apply) Landscape of Local Public Health Preparedness (i.e. knowledge of major agencies, guidance, and history) Public Health Emergency Preparedness Law Community Partnerships for Preparedness and Response All-Hazards Planning Planning for those Functional and Access Needs Medical Countermeasure Planning and Requirements Volunteer Management PHEP & HPP Funding Guidance Administrative Preparedness HSEEP and Exercise Planning Given the potential session topics listed above, please briefly elaborate on your experience in any of the listed topic(s) above (1,000 characters maximum). (Note: applicants may focus on 1-2 topics and need not touch on all selected topics)

7 Please indicate which additional preparedness areas that you have professional experience working with. (check all that apply) Isolation and Quarantine Recovery Emerging Infectious Diseases Pandemic Influenza Preparedness Accreditation and Recognition Programs (PHAB, PPHR) Risk Communications Hospitals / Healthcare Coalitions Pharmacy Partnerships Partnerships with Municipal Agencies (Emergency Management, Police, Fire, Emergency Medical Services) Radiation Preparedness Have you participated in any previous NACCHO activities, work groups, committees, or projects? (if Yes, briefly list which ones) No (1) Yes (2) Why would you like to be a mentor as part of this program? (1,000 characters maximum) Are you interested in presenting course material on any of the following topics? (select all that apply) Any of the topics listed below Public Health Preparedness History Examples of Local Public Health Department Response The Role of Local Preparedness Coordinators Federal Agencies Involved in Public Health Preparedness (ASPR, CDC, FDA, DHS, VA, etc.) Federal Public Health Preparedness Acts (PAHPRA, FDA Food, Drug, & Cosmetic Act, Stafford Act, PREP Act, etc.) Federal Public Health Preparedness Policies (National Health Security Strategy, National Response Framework, National Preparedness Guidelines, etc.) Public Health Emergency Preparedness Capabilities / Hospital Preparedness Capabilities Requirements and Funding Medical Countermeasure Requirements Current and Future Trends in Public Health Words of Wisdom for New Preparedness Coordinators No, I am not interested in presenting course material.

8 Do you currently have access to a webcam? (Note: responding "No" will not impact selection in this program) Yes No Briefly describe any relevant leadership or mentoring experience you have (1,000 characters maximum): Public Health Preparedness Experience Please select which statement(s) apply to your work experience history (select all that apply): Currently employed at a local health department Currently employed as a preparedness coordinator or other similar preparedness role (e.g. MCM Coordinator, SNS Coordinator, etc.) Currently employed as a preparedness director or other preparedness leadership role Previously employed at a local health department Previously employed as a preparedness coordinator or other similar preparedness role (e.g. MCM Coordinator, SNS Coordinator, etc.) Previously employed as a preparedness director or other preparedness leadership role Has experience as an Medical Reserve Corps (MRC) Unit leader None of the above Please indicate your years/months of local-level public health preparedness work experience. If no experience, enter "0". Years Months Please indicate your years/months of state-level public health preparedness work experience. If no experience, enter "0". Years Months

9 Please indicate your years/months of other public health preparedness work experience. If no experience, enter "0". Years Months Briefly describe and summarize your public health preparedness experience at the local level (describe role, major planning activities, responsibilities, and major exercise/response activities) (1,000 characters maximum): (Optional) You may upload a current version of your resume in lieu of submitting a response to the question above. Please note, applicants are not required to submit a resume as part of this process. Would you also like to apply for a mentor scholarship to supplement the cost of attending the Preparedness Summit? Yes No, thanks. I have other sources of funding to cover Preparedness Summit expenses. Mentor Scholarship Supplemental Application Some of the workshop modules may utilize the recent Ebola outbreak as a case study for discussion. Please briefly describe any activities you were involved with at your health department as part of the Ebola Response. (750 characters maximum) What lessons learned or important concepts would you like to share with new preparedness coordinators that attend this session? (750 characters maximum) If this scholarship is not awarded to you, will you still be able to attend the 2016 Preparedness Summit? Yes No Unknown

10 Please list the top three preparedness topics you would like additional information on as part of this program (note: these do not need to be previously listed session topics, but can be) If offered, would you be interested in using this workshop to apply to your continuing education credit requirements? Yes No If yes, which type of credit would you apply for? (select all that apply) CME CNE CECH MCHES CEU CPE AAVSB/RACE Audit Other

11 Please read the statements below and select those to which you agree: I am available to attend the in-person workshop on Monday, April 18, 2016 with travel on Sunday, April 17, I commit to viewing an orientation and training webinar(s) in advance of the Summit. I will to commit approximately hours (new preparedness coordinators) or hours (preparedness mentors) of time over the course of the year to program activities. I am able to participate in at least two learning and sharing conference calls, during regular work hours, following the workshop. I have the necessary approval from my supervisor to participate. Please include any other information you would like to share below. By clicking the right arrow button you will submit your application and finalize your responses. If you would like to change any of your answers you can go back to a previous question by selecting the left arrow button.