Key Informant Impact and Gap Feedback Tool - 2021 California Wildfires Disaster

Form Approved

OMB No. 0990-0379

Exp. Date 08/30/2023

Key Informant Impact and Gap Feedback Tool - 2021 California Wildfires Disaster

Overview

This tool tracks your counties emerging needs in health and social services (HSS) recovery key areas and jumpstarts the needs assessment process. Cal-OES and federal HHS recovery coordinators will be visiting your county to conduct recovery listening sessions, and this guide will help inform our time together. Gathering this information will support efficient recovery planning, and the development of courses of action.

Who Should Complete the Tool?

Persons with specific knowledge in each area should complete this tool. If it works for you to collate responses from your agency that would be helpful, but it is not necessary. We expect that we may receive multiple guides per agency. Participants can expect to dedicate roughly 1 to 3 hours to complete this questionnaire, depending on the number of respondents in your agency. Please complete the Program Lead contact information for each program area. We understand this may be duplicative, but this information will help us schedule the recovery listening sessions to maximize your time.

Priority Scale

Impact is a measure of the effect of an incident, while urgency is a function of time. Anything that has both high impact and high urgency should get the highest priority, while low impact and low urgency should result in the lowest priority.

		IMPACT
		Low	Medium	High
		Priorities in Color
URGENCY	High	Medium	High	High
	Medium	Low	Medium	High
	Low	Low	Low	Medium

Please return your completed tool or direct any questions to:

Melissa Smith, Melissa.Smith@CalOES.ca.gov

CAL-OES HSS Recovery Coordinator

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 1.65 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer

Key Informant Impact and Gap Feedback Tool - 2021 California Wildfires Disaster

Please check boxes and complete the blue shaded areas.

	Person Completing/Collating Tool
County:
Date:
Agency:
Name:
Position:
Program Area:
Email:
Phone:

Program	Has your ability to provide services in this area been compromised due to the disaster?		Has the request for services significantly increased in this area post disaster, AND is your agency unable to meet this increased need?		Program Lead Name: Email: Phone:	Given the impact and the urgency, please rate priority:
Public Health
Communicable Disease	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Chronic Disease	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Immunizations	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2:						☐ High ☐ Medium ☐ Low
Issue 3:						☐ High ☐ Medium ☐ Low
Maternal, Child & Adolescent Health	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
WIC	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Clinical Services	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
PHEP Program	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Public Health Laboratory	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Vital Records	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Data and Statistics	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Environmental Health
Food Quality	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Water Quality	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Air Quality	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Inspections and licensing	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Responder Health	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Env Health Laboratory	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Behavioral Health
Crisis Intervention	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Addiction Services	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Domestic & Sexual Violence	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Adult Mental Health	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Child Mental Health	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Social Services/Human Services
Crisis Financial Aid / Food Assistance	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Aging & Disability Services	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Intellectual & Developmental Disabilities	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Domestic & Sexual Violence	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Child Protective Services	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Child Welfare	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Childcare/Preschool	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Homeless Populations	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Indigenous Populations	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Immigrant & Migrant Populations	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Health Care Services
County Public Hospital	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
FQHC(s)	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe how your agency needs assistance. Please be as specific as possible. Copy paste as many rows as necessary. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Healthcare Coalition	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
K-12 Education
Facilities	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Transportation	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Technology, Data Systems and Equipment	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Student and Staff Housing	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Staff Health and Readiness	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Student Behavioral Health	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
National School Lunch Program	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Communications	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low
Additional Program add additional programs as necessary	YES ☐	NO ☐	YES ☐	NO ☐	Program Lead Name: Email: Phone:
If YES to either question, please describe in one sentence how your agency needs assistance. Copy and paste as many rows as necessary to capture each issue. Issue 1.						☐ High ☐ Medium ☐ Low
Issue 2.						☐ High ☐ Medium ☐ Low
Issue 3.						☐ High ☐ Medium ☐ Low

Please return your completed tool or direct any questions to:

Please contact:

Melissa Smith

CalOES HSS Recovery Coordinator

Melissa.Smith@CalOES.ca.gov

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