Is the agency affiliated with a: system Hospital care facility Long-term Neither Does the agency provide hospice services? Yes No What is the role of the agency in the community's pandemic influenza planning? ____________________________________________________________________ * Has it been discussed with Emergency Medical Services (EMS) what services they would provide for the agency's patients during an influenza pandemic? Yes No If yes, what are those services? _________________________________________________________________ * Have there been discussions with the community's hospital(s) on their expectations of the types or levels of services the agency will provide to patients during an influenza pandemic? Yes No If yes, what are services? _________________________________________________________________ Has the scope of services been defined for those the agency will provide and that will be referred to other providers? Yes No
Is the agency affiliated with a: Hospital system Long-term care facility Neither Does the agency provide hospice services? Yes No What is the role of the agency in the community's pandemic influenza planning? ____________________________________________________________________ * Has it been discussed with Emergency Medical Services (EMS) what services they would provide for the agency's patients during an influenza pandemic? Yes No If yes, what are those services? _________________________________________________________________ * Have there been discussions with the community's hospital(s) on their expectations of the types or levels of services the agency will provide to patients during an influenza pandemic? Yes No If yes, what are services? _________________________________________________________________ Has the scope of services been defined for those the agency will provide and that will be referred to other providers? Yes No
cat_cdc.docx