App C

HPP BP5 End-of-Year Performance Module in PERFORMS
Instructions For Awardees
BP5: July 1, 2016 to June 30, 2017
Prepared by:Hospital Preparedness Program (HPP)

Office of the Assistant Secretary for Preparedness and Response (ASPR)
U.S. Department of Health and Human Services (HHS) 1

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Version

August 4, 2017

Table of Contents
Introduction .................................................................................................................................................... 3
Module Sections and Forms ....................................................................................................................... 3
General Guidance ...................................................................................................................................... 4
Changes to Module from BP4 ..................................................................................................................... 4
Summary Form .............................................................................................................................................. 4
1.1.1 Cover .................................................................................................................................................... 5
1.2.1 HPP Expenditures Report ..................................................................................................................... 6
2.1.1 ESAR-VHP Program ............................................................................................................................. 8
3.1.1 Medical Surge ..................................................................................................................................... 10
4.1.1 Healthcare Coalitions (HCCs) (link and tab to section 4 and 5) ........................................................... 11
4.1.1 Healthcare Coalitions (HCCs) .......................................................................................................... 12
County Pop-Up ..................................................................................................................................... 13
Organization Pop-Up ............................................................................................................................ 14
4.2.1 Healthcare Coalition Organizations (HCOs) ..................................................................................... 15
4.3.1 National Incident Management Systems (NIMS) .............................................................................. 16
5.1.1 Medical Surge.................................................................................................................................. 17
5.2.1 Continuity of Operations .................................................................................................................. 18
5.3.1 Healthcare Coalition Developmental Assessment (HCCDA) ............................................................ 20
6.1.1 Penetration Rate ................................................................................................................................. 23
7.1.1 Other HPP Reporting .......................................................................................................................... 27
Reports ........................................................................................................................................................ 28
Awardee Level Report .............................................................................................................................. 28
Coalition Report ........................................................................................................................................ 28
Organization Report ................................................................................................................................. 28
Organization Details Report...................................................................................................................... 28
NIMS Report............................................................................................................................................. 28
Program Indicators and Factors Report .................................................................................................... 28

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Introduction
The purpose of this document is to provide instructions to assist awardees in completing the Hospital
Preparedness Program (HPP) Budget Period 5 (BP5) End-of-Year (EOY) Performance module in
PERFORMS. The HPP BP5 EOY Performance module includes the data indicators within the two program
measures (Medical Surge and Continuity of Healthcare Operations) and the healthcare coalition developmental
assessment (HCCDA) factors which were described in the HPP Measure Manual: BP5 Implementation
Guidance for HPP Program Measurement Activities. The module also includes fields for budget, Emergency
System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), and penetration rate.
Please note, even though the module was created to reflect the Implementation Guidance, the sections do not
directly reflect the organization of the Implementation Guidance. The sections are broken down based on
content and level of data aggregation and include all of the program indicators and factors within each section.

Module Sections and Forms
The BP5 End of Year (EOY) Performance Module will be populated with BP4 EOY data and will be available
for you to modify. The module consists of the following six sections and corresponding forms:
•

•
•

•

•

•
•

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Section 1 Cover and Financial: includes the Cover sheet and Financial forms
• Form 1.1.1 Cover: includes fields for awardee point of contact information and details regarding
the award
• Form 1.2.1 HPP Expenditures Report: includes fields for allocated, obligated and liquidated
funds for each HPP capability
Section 2 Data for Program measures: includes ESAR-VHP forms
• Form 2.1.1 ESAR-VHP Program: includes fields for all measures related to the Emergency
System for Advance Registration of Healthcare Professionals (ESAR-VHP) program
Section 3 Awardee Program Measure Indicators: includes forms for all of the Awardee level program
measures and related data indicators
• Form 3.1.1 Medical Surge: includes fields for all awardee level medical surge program
measures
Section 4 Healthcare Coalitions Information: includes all healthcare coalition and organization
information forms and links to section 5 forms
• Form 4.1.1 Coalition Details: includes fields for all healthcare coalition related information and
links to section 5 forms
• Form 4.2.1 Organizations: includes fields for all healthcare organization (HCO) information for
all of HCCs in the jurisdiction
• Form 4.3.1 NIMS: includes fields for National Incident Management System (NIMS) information
related to each hospital listed in the HCO form
Section 5 Healthcare Coalition (HCC) Program Indicators and Health Care Coalition Development
Assessment (HCCDA) Factors: includes all coalition level measure and HCCDA factor forms which can
be accessed using the links in the “4.1.1 Coalition Details” form
• Form 5.1.1 Medical Surge: includes fields for all coalition level medical surge program measures
• Form 5.2.1 COOP: includes fields for all coalition level Continuity of Healthcare Operations
(COOP) program measures
• Form 5.3.1 HCCDA: includes fields for all HCCDA factors
Section 6 Healthcare Coalition Information: includes all penetration rate information forms
• Form 6.1.1 Penetration Rate: includes fields for all penetration rate information for each type of
HCO
Section 7 Other HPP Reporting: includes forms to report any other information
• Form 7.1.1 Other HPP Reporting: includes an open text field to enter any other perdinent HPP
reporting information

General Guidance
The following guidance applies to the entire module.
•

•
•
•
•

A response is required in every field of each form (includes Cover sheet, Financial forms, ESAR-VHP
forms, awardee level Medical Surge forms, all coalition/organization/NIMS forms, all coalition level
medical surge, COOP, and HCCDA level forms for each identified coalition, and penetration rate form),
except for the telephone extension field for the point of contact on the “1.1.1 Cover” form, the coalition
weblink field on the “4.1.1 Coalition Details” form, and the 7.1.1 Other HPP Reporting form. Enter a “0”
in fields where you have zero counts and “NA” when there is no data to specify in text fields.
Spell-check and word count functions are available for all open-text fields.
Use “Save” buttons on each form to save any data entered onto the form. Use the“Cancel” button to
return to the previous web form without saving any entered data. Use “edit”, “delete”, and “add” buttons
to modify any records.
All HPP awardee users will be able to enter data into the module. However, only Awardee Level 1
users will be able to press the final submission button. Please note the final submission button can
only be pressed after all of the discrepancies have been addressed.
Joint measures should be reported on PHEP’s BP5 End of Year Program Measures Module.

Figure 1: The following table reflects a view of the inks on the main page of the PERFORMS BP5 HPP Performance module.
To navigate from one form to another, please use the links on the “Summary” form or the following tabs which are across the
top of the module (tabs listed below). All of the awardee-based forms can be navigated through these two mechanisms.
Additionally, you can navigate to the Reports form through the tabs at the top of the module.

Summary 1.1.1 1.2.1
2.1.1
3.1.1
4.1.1
6.1.1
7.1.1 Reports
Cover Financial ESAR- Awardees Healthcare Penetration Other
VHP
Coalitions Rate
(HCCs)

Changes to Module from BP4
•
•
•

The Cover sheet will be populated with the amount awarded according to the HPP BP5 Funding Table.
The Expenditures form will include allocated funds populated from the PERFORMS Program Budget
Module, but does not include any carryover funds.
Question 3.1.1.1 in form 3.1.1 Medical Surge (use shortcut tab “3.1.1 Awardee” to go to form) has been
updated to reflect how Crisis Standards of Care plans are being submitted via email to ASPR’s
Technical Resources, Assistance Center, and Information Exchange (TRACIE).

Summary Form
The “Summary” form below will be the main form in the HPP BP5 End of Year Performance Module. There are
links to all Awardee level forms, a SAMPLE of discrepancies that could be seen in the form, and the final
submission button.

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Figure 2: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s Summary form.

U.S. Department of Health and Human Services
HPP EOY Performance
Section 1: Cover and Financial
Form 1.1.1 Cover
*Optional field: Telephone Extension of HPP Point of Contact
1.1.1 Cover
1.2.1 HPP Expenditures
2.1.1 ESAR-VHP
3.1.1 Medical Surge
4.1.1 Healthcare Coalition
6.1.1 Penetration Rate
7.1.1 Other
Reports
View Discrepancies
Final Submission

First Name is “null” on cover form
No obligated $ to this capability – Healthcare System Preparedness
No Liquidated $ to this capability – Fatality Management

1.1.1 Cover
This form provides HPP with basic Awardee information and can be accessed using the “1.1.1 Cover” link on
the “Summary” form or the tab at the top of the module. The fields Grantee Name, Report Type, and Grant
Year of HPP Award will populate with the following fixed text: “Awardee’s name”, “End of Year”, and “BP5”,
respectively. The field HPP Award Amount, will be populated with data from the HPP BP5 Funding Table. All
other fields will be populated with BP4 End of Year data, but will allow the user to modify the data. Please note
that all fields except for telephone extension of HPP point of contact are required.

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Figure 3: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s 1.1.1 Cover form.

U.S. Department of Health and Human Services
HPP EOY Performance
Section 1: Cover and Financial
Form 1.1.1: Cover
*OPTIONAL FIELD: TELEPHONE EXTENSION OF HPP POINT OF CONTACT
HPP Cover Information

Response

Grantee Name*

Populated with awardee name

Last Name of HPP Point of Contact

500 character limit

First Name of HPP Point of Contact

500 character limit

Telephone (xxx-xxx-xxxx) of HPP Point of
Contact

Phone number 12 character length, including dashes. Must be in
xxx-xxx-xxxx format

Telephone Extension of HPP Point of
Contact

Numeric field, 10 characters in length. Please put “N/A” in the
telephone extension field for HPP Point of Contact if not
applicable.

Email Address of HPP Point of Contact

Email address—must be valid email with name@domain.com. -50 character limit

Report Type*

Populated with the text “End of Year”

Grant Year of HPP Award*

Populated with data from the BP5 Funding Table

HPP Award Amount*

Populated with Total Award Amount Allocated from Populated
with data from the BP5 Funding Table

Name of Authorized HPP Certifying
Official

500 character limit.

Title of Authorized HPP Certifying Official

500 character limit.

*These fixed fields are populated with data and can not be changed by the user.

1.2.1 HPP Expenditures Report
This form provides budget information for each HPP capability and can be accessed using the “1.2.1 HPP
Expenditures” link on the “Summary” form or the tab at the top of the module. The “Allocated” column should
be filled with the amount set aside to spend on activities related to each capability. The fields for allocated
amounts will be populated with budget data as of June 30, 2017, including all redirects, from the PERFORMS
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Program Management module, but will not include any carryover funds. The “Obligated” column should be
filled with the total amount of contracts and other formal agreements that you have entered into to commit
spending for activities related to each capability. This amount must be equal to or less than the amount in the
“Allocated” column. The “Liquidated” column should be filled with the amount of “Obligated” fund that has been
spent (e.g., paid invoices). This amount must be less than or equal to the amount in the “Obligated” column.
The “Remaining Allocated Funds” column is a self-calculating column that is the difference between the
“Allocated” and “Obligated” column for each capability. You do not need to fill this out. All “Allocated,
“Obligated”, and “Liquidated” fields must be filled with dollar amounts greater than or equal to zero. We do not
require reporting of any administrative funding in this report, so the total funds reported in the form will NOT
match the total award amount.
Figure 4: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s 1.2.1 HPP Expenditures
Report form.

HPP EOY Performance
Section 1: Cover and Financial
Form 1.2.1: HPP Expenditures Report
*All Allocated, Obligated, and Liquidated fields must be filled
Budgeted Amounts
Name of HPP
Capability

Remaining
Allocated
Funds

Allocated

Obligated

Liquidated

Capability 1: Healthcare
System Preparedness

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 2: Healthcare
System Recovery

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 3: Emergency
Operations Coordination

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 5: Fatality
Management

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

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Capability 6: Information
Sharing

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 10: Medical
Surge

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 14: Responder
Safety and Health

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Amount must
be greater or
equal to zero

Amount must be
greater or equal to
zero and less than
or equal to allocated

Amount must be
greater or equal to
zero and less that or
equal to obligated

Calculated field:
allocated minus
obligated

Capability 15: Volunteer
Management

2.1.1 ESAR-VHP Program
This form includes fields related to the Emergency System for Advance Registration of Healthcare
Professionals (ESAR-VHP) measures and can be accessed using the “2.1.1 ESAR-VHP” link on the
“Summary” form or the tab at the top of the module. All of the fields require a response of either Yes/No OR a
number greater than or equal to zero. For any contextual questions related to this specific form, please contact
the ESAR-VHP mailbox.

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Figure 5: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s 2.1.1 ESAR-VHP Program
form.

HPP EOY Performance
Section 2: Data for Program measures
Form 2.1.1: ESAR-VHP Program
ESAR-VHP Program Requirement

Response

2.1.1.1 Does the State currently have an operational electronic registration system for
recording and managing volunteer information based on the electronic system
requirements presented in the ESAR-VHP Compliance Requirements and data
definitions presented in the ESAR-VHP Guidelines?

Drop down: “Yes”,
“No”

2.1.1.2 Has the State developed expedited ESAR-VHP registration and credential
verification processes to facilitate the health response immediately after a disaster or
public health emergency?

Drop down: “Yes”,
“No”

2.1.1.3 Is the ESAR-VHP system capable of assigning volunteers to one of four ESARVHP credential levels?

Drop down: “Yes”,
“No”

2.1.1.4 Is the electronic system capable of recording all volunteer health
professional/emergency preparedness affiliations of an individual, including local,
State, and Federal entities?

Drop down: “Yes”,
“No”

2.1.1.5 Is the electronic system capable of identifying volunteers willing to participate in
a federally coordinated emergency response?

Drop down: “Yes”,
“No”

2.1.1.6 Is the State capable of updating volunteer information and re-verifying
credentials annually?

Drop down: “Yes”,
“No”

2.1.1.7 Can the State or Territory query its ESAR-VHP system to generate a list of
potential volunteer health professionals, by discipline and credential level, within 2
hours of a request being issued by a requesting body or the HHS Secretary’s
Operations Center (SOC)?

Drop down: “Yes”,
“No”

2.1.1.8 Can the State or Territory provide a verified list of available volunteer health
professionals, by discipline and credential level, within 24 hours of a request being
issued by a requesting body or the HHS SOC?

Drop down: “Yes”,
“No”

2.1.1.9 Has the State developed a plan to recruit and retain volunteers?

Drop down: “Yes”,
“No”

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2.1.1.10 Has the State developed a plan for coordinating with all volunteer health
professional/emergency preparedness entities to ensure an efficient response to an
emergency, including but not limited to Medical Reserve Corps (MRC) units, the
National Disaster Medical System (NDMS) teams, and the Federal Emergency
Management (FEMA) Citizens Corps?

Drop down: “Yes”,
“No”

2.1.1.11 Has the State developed protocols for deploying and tracking volunteers
during an emergency (Mobilization Protocols)?

Drop down: “Yes”,
“No”

2.1.1.12 Has the State tested its ESAR-VHP system in a drill, exercise, or actual
incident?

Drop down: “Yes”,
“No”

2.1.1.13 How many volunteers (health professional and non-health professional) are
registered in the ESAR-VHP system? (Number)

≥0

2.1.1.14 Of the total number of registered volunteers, how many are affiliated with the
Medical Reserve Corps (MRC)? (Number)

≥0

2.1.1.15 Of the total number of registered volunteers, how many are affiliated with the
National Disaster Medical System (NDMS)? (Number)

≥0

3.1.1 Medical Surge
This form contains three medical surge indicators at the awardee level and can be accessed using the “3.1.1
Awardees” link on the “Summary” form or the tab at the top of the module. Each indicator requires a single
digit response of 1 through 9 which relates to a 9-point Likert scale. Please refer to the HPP Measure Manual:
BP5 Implementation Guidance for HPP Program Measurement Activities for a detailed description of the 9point Likert scale and related qualifying descriptors.
Please note that the for measure 3.1.1 has been modified slightly. In January 2017, the Community of Interest
(COI) SharePoint site was migrated to ASPR’s Technical Resources Assistance Center and Information
Exchange (TRACIE) under the Crisis Standards of Care (CSC) Topic Collection. Awardees may submit their
approved CSC plan to TRACIE mailbox. The submitted plans will be reviewed by TRACIE’s cadre of subject
matter experts and promising practices/templates will be posted under the CSC Topic Collection.
If you still have questions after reviewing the implementation guidance, please contact the SHARPER mailbox.

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Figure 6: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s 3.1.1 Medical Surge form.

HPP EOY Performance
Section 3: Awardee Program Measure Indicators
Form 3.1.1: Medical Surge (Includes the following capabilities: Healthcare System Preparedness,
Healthcare System Recovery, Fatality Management, Medical Surge)
*Please provide a response value of 1-9 for each awardee program indicator
Response Scale Definitions
“1”--Strongly Disagree--Does not meet indicator/factor to a very large extent
“2”--Disagree--Does not meet indicator/factor to a large extent
“3”--Moderately Disagree--Does not meet indicator/factor but making minimal progress
“4”--Slightly Disagree--Does not meet indicator/factor but making some progress
“5”--Neither Agree nor Disagree--Undecided
“6”--Slightly Agree--Meets achievement of the indicator/factor with minimal progress
“7”--Moderately Agree--Meets achievement of the indicator/factor with some progress
“8”--Agree--Meets achievement of the indicator/factor to a large extent
“9”--Strongly Agree --Meets achievement of the indicator/factor to a very large extent
Awardee Indicators

Response

3.1.1.1 The Awardee has posted its approved Crisis Standards of Care plan
on the ASPR Communities of Interest SharePoint Site or submitted it to
ASPR’s Technical Resources Assistance Center and Information Exchange
at TRACIE mailbox. Please see pages 10-11 on the HPP BP5 EOY
template for further information.

Numeric field that allows for a
single digit value in the range of
1 to 9

3.1.1.2 The Awardee has completed mass fatality management plans that
have been adopted by HCC members.

Numeric field that allows for a
single digit value in the range of
1 to 9

3.1.1.3 The Awardee’s Recovery Plan addresses how it will meet postdisaster behavioral and mental healthcare needs of communities (i.e., HCC
member staff).

Numeric field that allows for a
single digit value in the range of
1 to 9

4.1.1 Healthcare Coalitions (HCCs) (link and tab to section 4 and 5)
You can navigate to section 4 and section 5 of the module through the “4.1.1 Healthcare Coalitions (HCCs)”
link on the “Summary” form or tab at the top of the module. The link/tab will navigate you directly to three
subtabs which correspond to the following forms: “4.1.1 Coalition Details”, “4.2.1 Organizations (HCOs)”, and
“4.3.1 NIMS (see table below)”.
Figure 7: The following table reflects a view of the sub-tabs within the PERFORMS BP5 HPP EOY Performance Module’s 4.1.1
Coalitions tab.

4.1.1 Coaltion
Details
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4.2.1
Organizations

4.3.1
NIMS

4.1.1 Healthcare Coalitions (HCCs)
This form includes fields related to describing each healthcare coalition (HCC) within the awardee’s jurisdiction
and can be accessed using the “4.1.1 Healthcare Coalitions (HCCs)” link on the “Summary” form or the tab at
the top of the module. All fields except for the Web Link field are required. To modify or delete records, use
the edit/delete links under the action column. You can add coalitions by using the “ADD COALITION” button at
the bottom.
For each coalition, please make sure to provide the full legal name. Also, please use the “Edit” button under
County/Zip Code to enter information on the coalition coverage area. The Coalition County Pop-up box will
pop up (See below). *Alaska will show zip codes, while some other states will show cities, towns, and
parishes, etc.
In order to associate member organizations to the Coalitions, please first enter healthcare coalition member
organizations information under the “4.2.1 Healthcare Organizations” form which is accessible using the “4.2.1
Organizations” tab. Enter a unique full legal name for each organization regardless of organization type. After
inputting the organizations, you will then return to the “4.1.1. Coalition Details” form to identify the organizations
within each coalition. To do so, click the “Associate” button to open a pop-up box listing all HCC organizations
within the Awardee. Then click on all the member organizations associated with each coalition.In the far right
column entitled “Factors”, press the “Program Indicators” link for each coalition. This link will direct you to go to
the coalition-level indicator forms of “5.1.1 Medical Surge”, “ 5.2.1 Continuity of Healthcare Operations”, and
“5.3.1 Healthcare Coalition Developmental Assessment”.
A document in the User Support folder in the Resource library includes both the definitions of a healthcare
coalition and HCC member types.The character limits for each of the coalition point of contact fields and web
link field are listed below.

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Figure 8: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s 4.1.1 Coalition Details
form.

HPP EOY Performance
Section 4: Healthcare Coalitions Information
Form 4.1.1: Healthcare Coalitions (HCCs)
*OPTIONAL FIELD: WEB LINK
Act
ion

Edit

Name
of
HCC

Cou
nty/

500
chara
cters

Cou
nty
A;
Edit
Cou
nty
B

Del
ete

Edit
Del
ete

500
chara
cters

POC
Name

Zip
Cod
e

Edit

500
chara
cters

500
chara
cters

POC
Addr
ess

POC
City

500
chara
cters

500
chara
cters

500
chara
cters

500
chara
cters

PO
C
Sta
te

Abb
rev
list

Abb
rev
list

POC
Zip

PO
C
Ph
one

POC

Web
link

5
chara
cters

xxx
xxx
xxx
x

50
chara
cters

500
chara
cters

5
chara
cters

xxx
xxx
xxx
x

50
chara
cters

500
chara
cters

email

Associ
ate
Organi
zation
to
Coaliti
on

Associate

Associate

Fact
ors

Progr
am
Indic
ators

Progr
am
Indic
ators

Add New Coalition

County Pop-Up
This box will come up when the “Edit” button is pressed under the county/zip code on “4.1.1 Coalition Details”
form. Counties for each specific awardee are prepopulated and will be listed in alphabetical order. *Alaska will
show zip codes, and some other states will show cities and/or, towns instead of counties. Counties will be prechecked for all of the based on what was reported in HPP BP4 End of Year Performance module. You may
modify this by clicking on different counties or pressing the select all box. You may also search for specific
counties.

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Figure 9: The following table reflects a view of the PERFORMS BP5 HPP EOY Performance Module’s county pop-up box
within the 4.1.1 Coalition Details form.

County list for Coalition: Coalition A
Please select all of the items below that describe the coalition coverage area. You may search for specific
items using the search box in the header
Search
Select All
Cobb

Edward

Gwinnett

Long

Noll

Dekalb

Fulton

Hack

Marriot

Ung

Please Specify (Enter the name of each county separated by a semi-colon “;”):

Organization Pop-Up
This box will come up when the “Associate” button is pressed under the associate organization to coalition on
the “4.1.1 Coalition Details” form. The alphabetized organization list has been prepopulated within HCOs listed
in the “4.2.1 Healthcare Organizations” form. Respondents are asked to update or modify the list.
Organizations will be pre-checked based on what was reported in BP4. You may modify this by clicking on
different organizations or pressing the “select all button”. You may also search for specific organizations.
Figure 10: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s organization pop-up box
within the 4.1.1 Coalition Details form.

Organization list for Coalition: Clarke Cooperative
Please select all of organizations below that are part of the coalition. You may search for specific items using
the search box in the header
Search
Select All
Emergency
Mgmt

Fire Dept

Hospital B

Hospital D

EMS

Hospital A

Hospital C

Hospital E

Please Specify (Enter the name of each county separated by a semi-colon “;”):

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Police
Dept
Volunteer
Org

4.2.1 Healthcare Coalition Organizations (HCOs)
This form includes fields related to each organization that is associated with the jurisdiction’s coalitions. The
form can be accessed using the “4.1.1 Healthcare Coalitions (HCCs)” link on the “Summary” form or the tab at
the top of the module and then going to the “4.2.1 Organizations” subtab to get to the form. The following form
should be used to list all of the member organizations that are part of a healthcare coalition. Please enter
healthcare coalition organizations and provide their full legal name. You can use the “Edit” and “Delete” links
to modify each record or add a record using the “Add Organization” button. The “Name of HCC” field is there
for your convenience and can not be modified. The “Name of the HCC” is assigned to each organization in the
“4.1.1 Coalition Details” form through that associates organizations to coalition. An organization may be
associated with more than one healthcare coalition. You may sort the list of organizations by coalition name
and then organization name or just by organization name.
Please note we are only asking you to report on NIMS information for all healthcare coalition organizations that
are categorized under HCC Member organization type as “Hospital”. For “Hospital” coalition members, you will
be asked, “Do you meet any of the 11 NIMS compliance components?” When you mark the answer as “Yes”,
press the “View/Edit NIMS” link to go the NIMS form to update NIMS information for the hospital. If other
coalition member types are selected, the NIMS-related columns cannot be answered (they will be greyed out).
Please make sure to go to “4.3.1 NIMS” form or the “NIMS” pop-up form, which activates upon pressing the
“View/Edit NIMS” link, and update all NIMS components for each “Hospital” (regardless if you have completed
or not applicable data for each NIMS component).
Figure 11: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 4.2.1 Healthcare Coalition
Organizations form.

HPP EOY Performance
Section 4: Healthcare Coalition Information
Form 4.2.1: : Healthcare Coalition Organizations (HCOs)
*Please provide NIMS information on only the following organizations categorized as “Hospital”
member types
*Go back to the coalition details page to associate each HCO to a coalition
Action

Name of the
Organization

HCC
Member
Organization
type

If the HCC participated in an
HPP funded exercise in the
past year, please indicate the
type

Do you meet
any of the 11
NIMS
compliance
components?

500 characters

**drop down
(see below)

Drop down: “Full Scale
Exercise”, “Functional
Exercise”, “NA”

Drop down:
“Yes”, “No”

500 characters

**drop down
(see below)

Drop down: “Full Scale
Exercise”, “Functional
Exercise”, “NA”

Drop down:
“Yes”, “No”

Edit
Delete
Edit
Delete

Add Organization

15

Association
to NIMS

View/Edit
NIMS

**Drop down list for coalition member organization type includes: Hospital; Skilled Nursing Facility;
Psychiatric Residential Treatment Facility; Home Health Agency; Hospice; End Stage Renal Disease;
Rural Health Clinic; Ambulatory Surgical Center; Community Mental Health Center; Federally Qualified
Health Center; Community Health Center; Local Health Department; Emergency Medical Services;
Emergency Management Agency; Other.

4.3.1 National Incident Management Systems (NIMS)
The form includes NIMS fields for each hospital listed in the “4.2.1 Healthcare Coalition Organizations” form.
The form can be accessed using the “4.1.1 Healthcare Coalitions (HCCs)” link on the “Summary” form or the
tab at the top of the module and then going to the “4.3.1 NIMS” sub-tab to get to the form.
For each coalition member organization which lists its’ member type as Hospital, NIMS information (if the
organization meets any of the 11 NIMS criteria) is required. The “Name of Organization” will be populated with
text from the “4.2.1 Healthcare Coalition Organization” form. You simply must update each of the eleven
criteria with an “X” for completed, “IP” for in progress, and “NP” for no progress.
There are two methods to enter NIMS data. One method allows the user to only view and edit NIMS
information for a single hospital using the “View/Edit NIMS” link on “4.2.1 Healthcare Coalition Organization”
form. Another method allows the user to view and edit all NIMS records using the “4.3.1 National Incident
Management Systems (NIMS)” form. You can not add new records to the “4.3.1 National Incident
Management Systems (NIMS)” form. You may only add records using the “4.2.1 Healthcare Coalition
Organization” form.

16

Figure 12: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 4.3.1 National Incident
Management Systems (NIMS) form.

HPP EOY Performance
Section 4: Healthcare Coalition Information
Form 4.3.1: National Incident Management System (NIMS)
*Please fill out the following NIMS form for each coalition member organization that was categorized as a
“Hospital” in 4.2.1
For each NIMS compliance indicator, please describe compliance using the following codes:
"X" = if the indicator is “Completed”
"IP" = if the indicator is “In Progress”
"NP" = there has been “No Progress” on the indicator
Name of
Organizati
on

Sherman
Hospital

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

NIMS

1

2

3

4

5

6

7

8

9

10

11

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

Drop
down:
“X”,
“IP”,
“NP”

5.1.1 Medical Surge
The “5.1.1 Medical Surge” form includes fields for all coalition level program measures and associated data
indicators. The form which in a pop-up screen can be accessed using the “Program Indicators” link on the
“4.1.1 Coalitions Details” form for each coalition. The awardee can then navigate to the “5.1.1 Medical Surge”
form using the “5.1.1 Medical Surge” tab in the pop-up screen.
Each data indicator requires a single digit response of 1 through 9 which relates to a 9-point Likert scale.
Please refer to the HPP Measure Manual: BP5 Implementation Guidance for HPP Program Measurement
Activities for a detailed description of the 9-point Likert scale and related qualifying descriptors.

17

Figure 13: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 5.1.1 Medical Surge form.

HPP EOY Performance
Section 5: Healthcare Coalition Program Indicators and Factors
Form 5.1.1: Medical Surge (Includes the following capabilities: Healthcare System Preparedness,
Healthcare System Recovery, Medical Surge)
*Please provide a response value of 1-9 for each healthcare coalition program indicator.
HCC Indicators

Response

5.1.1.1 The HCC has developed a strategic plan with participation from its
membership.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.1.1.2 The HCC has demonstrated, through exercise or real incident, its
ability to both deliver appropriate levels of care to all patients, as well as to
provide no less than 20% immediate availability of staffed members' beds,
within 4 hours of a disaster.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.1.1.3 The HCC has demonstrated the ability to do the following during an
incident, exercise or event: monitor patient acuity and staffed bed availability
in real-time, off-load patients, on-load patients, and track and document
patient movement

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.1.1.4 The HCC has a mechanism to obtain feedback to help resolve
member conflicts that have the potential to affect the overall performance of
the HCC.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1 Continuity of Operations
This form includes fields for all coalition level continuity of healthcare operations (COOP) program measures
and associated data indicators. The form which is in a pop-up screen can be accessed using the “Program
Indicators” link on the “4.1.1 Coalitions Details” form for each coalition. The awardee can then navigate to the
“5.2.1 Continuity of Operations” form using the “5.2.1 COOP” tab in the pop-up screen.
Each data indicator requires a single digit response of 1 through 9 which relates to a 9-point Likert scale.
Please refer to the HPP Measure Manual: BP5 Implementation Guidance for HPP Program Measurement
Activities for a detailed description of the 9-point Likert scale and related qualifying descriptors.

18

Figure 14: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 5.2.1 Continuity of
Operations form.

HPP EOY Performance
Section 5: Healthcare Coalition Program Indicators and Factors
Form 5.2.1: Continuity of Operations (Includes the following capabilities: Healthcare System
Preparedness, Healthcare System Recovery, Medical Surge
*Please provide a response value of 1-9 for each healthcare coalition program indicator.
Healthcare Coalition Program Indicators

Response

5.2.1.1 The HCC has access to a risk-based HVA which prioritizes the risks
to its members.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.2 The HCC has conducted a gap analysis to identify resource shortfalls
during an event and is implementing plans to close those resource gaps.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.3 The HCC has a process to enhance its member’s situational
awareness to support activation of immediate bed availability through
continuous monitoring.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.4 The HCC has demonstrated the capability of a redundant means of
communication for achieving and sustaining situational awareness.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.5 The HCC has tested its ability to address its member’s healthcare
workforce safety needs through training and resources.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.6 The HCC has prioritized and integrated essential healthcare recovery
needs in its Emergency Operation Plan.

Numeric field that allows for a
single digit value in the range
of 1 to 9

5.2.1.7 The HCC has achieved its exercise objectives during tests of state or
regional healthcare disaster plans.

Numeric field that allows for a
single digit value in the range
of 1 to 9

19

5.3.1 Healthcare Coalition Developmental Assessment (HCCDA)
This form includes fields for all coalition level HCCDA factors. The form which in in a pop-up screen can be
accessed using the “Program Indicators” link on the “4.1.1 Coalitions Details” form for each coalition. The
awardee can then navigate to the “5.3.1 Healthcare Coalition Developmental Assessment (HCCDA) factors”
form using the “5.3.1 HCCDA” tab in the pop-up screen.
Each data indicator requires a single digit response of 1 through 9 which relates to a 9-point Likert scale.
Please refer to the HPP Measure Manual: BP5 Implementation Guidance for HPP Program measurement
Activities for a detailed description of the 9-point Likert scale and related qualifying descriptors.
For question 5.3.1.20, please use the drop-down box to select an answer. If an answer of “Other” is provided,
then question 5.3.1.20.1 will be visible.
Figure 15: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 5.3.1 Healthcare Coalition
Developmental Assessment (HCCDA) factors form.

HPP EOY Performance
Section 5: Healthcare Coalition Program Indicators and Factors
Form 5.3.1: Healthcare Coalition Developmental Assessment
Please provide a response value of 1-9 for each healthcare coalition program indicator.
Please enter a “N/A” in 5.3.1.20.1 if the answer is not applicable
HCC Indicators

Response

5.3.1.1 The HCC has established a formal self-governance structure,
including leadership roles.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.2 The HCC has multi-disciplinary healthcare organization
membership.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.3 The HCC has established its geographical boundaries.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.4 The HCC has a formalized process for resource and information
management with its membership.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.5 The HCC is integrated into the healthcare delivery system
processes for their jurisdiction (e.g., EMS, referral patterns, etc.).

Numeric field that allows for a
single digit value in the range of 1
to 9

20

5.3.1.6 The HCC has established roles and responsibilities.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.7 The HCC has conducted an assessment of each of its member’s
healthcare delivery capacities and capabilities.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.8 The HCC has engaged its member’s healthcare delivery system
executives.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.9 The HCC has engaged its member’s healthcare delivery system
clinical leaders.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.10 The HCC has an organizational structure to develop
operational plans.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.11 The HCC has an incident management structure (e.g., MACC,
ICS) to coordinate actions to achieve incident objectives during
response.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.12 The HCC demonstrates an ability to enhance situational
awareness for its members during an event.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.13 The HCC demonstrates an ability to identify the needs of at-risk
individuals (e.g., electrically dependent home-bound patients,
chronically ill) during response.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.14 The HCC demonstrates resource support and coordination
among its member organizations under the time urgency, uncertainty,
and logistical constraints of emergency response.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.15 The HCC members demonstrate an evacuation capability with
functional patient tracking mechanisms.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.1 6 The HCC utilizes an operational framework and set of
indicators to transition from crisis standards of care, to contingency, and
ultimately back to conventional standards of care.

Numeric field that allows for a
single digit value in the range of 1
to 9

21

5.3.1.17 The HCC incorporates post-incident health services recovery
into planning and response.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.18 The HCC ensures quality improvement through
exercises/events and corrective action plans.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.19 The HCC has an established a method (e.g., social network
analysis) for incorporating feedback from its members to support group
cohesion and improve processes.

Numeric field that allows for a
single digit value in the range of 1
to 9

5.3.1.20 Within the past year, what is your HCC’s MOST IMPORTANT
accomplishment related to emergency preparedness, response,
recovery, and/or mitigation? (Choose one)

Drop down box with choices written
below

5.3.1.20.1 Other Specified

100 characters

***5.3.1.20 Drop down list:
1-Enhanced connectivity with Emergency Operations Center (EOC) and Emergency Operations Plan (EOP);
2-Improved leveraging of disparate funding streams;
3-Increased ability to leverage resources and allocate scarce resources between HCC members;
4-Increased availability of emergency response and recovery services for the jurisdiction, bridging response
and recovery;
5-Increased educational training opportunities for healthcare organizations;
6-Increased emergency management skills among HCC organizations;
7-Increased exercising and readiness planning among HCC members (e.g., drills and exercises);
8-Increased formal agreements for resource and information exchange;
9-Increased information sharing between HCC members through integrated communication;
10-Increased or enhanced sources of data needed for emergency preparedness and response;
11-Increased volunteerism (e.g., Emergency System for Advance Registration of Volunteer Health
Professionals);
12-Other (please describe below)

22

6.1.1 Penetration Rate
This form includes fields for both the BP4 and BP5 penetration rate for each coalition healthcare organization
type and can be accessed using the “6.1.1 Penetration Rate” link on the “Summary” form or the tab at the top
of the module. Please include, by member type, the number of organizations that participated in your
jurisdiction’s coalitions and the total number of healthcare organizations and community partners in your
jurisdiction at the end of BP5 (June 30, 2017). We request that you use the same definitions of HCC member
types and data resources that were used when you provided your previous End of Year information. While
these HCC member type definitions may vary slightly across awardees, reporting consistency by awardee will
afford meaningful analyses across budget periods. A document in the User Support folder in the Resource
library includes both the definitions of a healthcare coalition and HCC member types.
The “HCC Member Count” and “Total Number of Healthcare and Other Community Partners” fields are split
into BP4 and BP5 columns. The BP4 columns are fixed fields that display the data reported in BP4 End of
Year Performance module, for your reference. The “BP5 HCC Member Count” requires a number less than or
equal to the “BP5 Total Number of Healthcare and Other Community Partners” field on the corresponding
column. The “BP5 Total Number of Healthcare and Other Community Partners” field requires a number of zero
or greater. The “Penetration Rate” field is an automatically calculated field based on “HCC Member Count”
divided by “Total Number of Healthcare and Other Community Partners” for each Member Type for each year
when “Total Number of Healthcare and Other Community Partner” for each Member type is greater than zero
and are provided for your convenience. The “Penetration Rate” field is updated when the “Save” button at the
bottom of the page is pressed.
Figure 16: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 6.1.1 Penetration Rate form.

HPP EOY Performance
Section 6: Healthcare Coalition Information
Form 6.1.1: Penetration Rate

HCC Member Type

Hospital

23

HCC Member Count

Total Number of
Healthcare and Other
Community Partners

Penetration Rate for BP5

BP4 BP5

BP4 BP5

BP4 BP5

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Greater than or equal
to zero

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Skilled Nursing
Facility

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Psychiatric
Residential Treatment
Facility

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Home Health Agency

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Greater than or equal
to zero

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Hospice

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Greater than or equal
to zero

End Stage Renal
Disease

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

24

Greater than or equal
to zero

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Rural Health Clinic

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Greater than or equal
to zero

Ambulatory Surgical
Center

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Community Mental
Health Center

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Federally Qualified
Health Center

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Community Health
Center

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

25

Greater than or equal
to zero

Local Health
Department

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Emergency Medical
Services

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Emergency
Management Agency

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Greater than or equal
to zero

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Other*

Greater than or equal
to zero and less than
and equal to the Total
Number of Healthcare
and Other Community
Partners
corresponding row
Calculated by
summing coalition
member type numbers
in the column; greater
than or equal to zero;
field can be modified

Calculated by
summing Total
Number of
Healthcare and Other
Community Partners
in the column; greater
than or equal to zero;
field can be modified

Automatically
calculated field (BP5
HCC Member divided
by Total when Total is
greater than zero);
format ##.#%

Total (calculated)

26

7.1.1 Other HPP Reporting
This form is an optional form and can be accessed using the “7.1.1 Other HPP Reporting” link on the
“Summary” form or the tab at the top of the module. Users can use this optional form to provide granularity on
any of their answers. The form contains an open text field that has a 3500 character limit. A spell check
button will be provided at the bottom of the form.
Figure 17: The following table reflects a view of the PERFORMS BP5 HPP Performance Module’s 7.1.1 Other HPP Reporting
form.

HPP EOY Performance
Section 7: Other HPP Reporting
Form 7.1.1: Other HPP Reporting
*Please use the following optional form to provide any in-depth information on items such as the program
measures, best practices, and coalition development.
3500 characters

27

Reports
The reports form has four report options. Click on a report name and then click view report. A pop-up box will
display the report. You may save the report in .pdf, .doc, or .xls formats by clicking on the floppy disk icon in
the pop-up box.
Figure 18: The image below reflects the pop-up box that allow users to generate and download a report.

HPP Reports
• Awardee Level Report
• Coalition Report
• Organization Report
• Organization Details
Report
• NIMS Report
• Program Indicators and
Factors Report

Awardee Level Report
The Awardee Level Report displays all data reported at the awardee level. This includes information from the
“1.1.1 Cover”, “1.2.1 HPP Expenditures Report” , “2.1.1 ESAR-VHP Program”, “3.1.1 Medical Surge”, “4.3.1
Penetration Rate”, and “7.1.1 Other HPP Reporting”.

Coalition Report
The Coalition Report displays all data reported on form “4.1.1 Coalition Details”.

Organization Report
The Organization Report displays all data reported on form “4.2.1 Healthcare Coalition Organizations”.

Organization Details Report
The Organization Details report displays all linked data from the following forms: “4.1.1 Coalition Details”,
“4.2.1 Healthcare Coalition Organizations” and “4.3.1 National Incident Management Systems (NIMS)”.

NIMS Report
The Organization Report displays all data reported on form “4.3.1 National Incident Management Systems
(NIMS)”.

Program Indicators and Factors Report
The Program Indicators Report displays all program indicators and HCCDA factors reported by coalition. This
data was recorded on forms “5.1.1 Medical Surge”, “5.2.1 Continuity of Operations”, and “5.3.1 Healthcare
Coalition Development Assessment (HCCDA) factors”.

28