0920-1352 Capability 3 01MAR2022

Form Approved

OMB Approval No. 0920-1352

Expiration Date: 10/31/2024

Capability 3

Date of most recent preparedness plans (or annexes) review or update

Subject matter experts involved in developing plans

EOC or public health functions within another EOC, including

a. Pre-event indicators

b. Notifications

c. Levels of activation

d. Staffing plans

e. Demobilization

Plans include identified general and command staff roles:

a. Incident commander /Unified Command

b. Finance/administration section chief

c. Logistics section chief

d. Operations section chief

e. Planning section chief

f. Public Information Officer (PIO)

g. Chief medical officer

h. Chief science officer

i. Epidemiologist

j. Infectious Disease/Influenza SME

k. Liaison officer

l. Safety officer

Process or procedures to request additional personnel and material resources from outside the health department and/or jurisdiction

Plans document processes required to support response including:

a. Administrative preparedness

b. Allocating and tracking funding and resources

c. Incident action plans (IAPs)

d. Situation Reports

COOP plans identify:

a. Essential public health services

b. Orders of succession

c. Devolution

d. Alternate location(s)

Public reporting burden of this collection of information is estimated to average 120 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1352).