Various agencies across Santa Cruz County are a part of the Coalition for Health and Medical Preparedness of Santa Cruz (CHAMPS). CHAMPS member organizations work together during an emergency to support the medical health needs of the county.
See a full list of HCC participating organizations
HCC Member Information
Respond to a Disaster
During a Department Operations Center (DOC) activation, complete the relevant forms and e-mail them to: HSADoc@santacruzcounty.us
Use Adobe Acrobat to fill out the forms. Other programs (including the Microsoft Edge web browser) may not save data or support the Email Now function that is located on each form.
If you have trouble emailing, fax to (831) 454-5068 or (831) 454-4488. Call the DOC with any questions at (831) 454-4444.
Situation Status Forms
Situation Status Form (PHDOC-01)
Report general facility status to Emergency Preparedness and Response.
Download
Resource Request Forms
Resource Request Form - Supplies and Equipment (PHDOC-02)
Submit a request for additional supplies in the event of an emergency.
Download
Resource Request Form - Personnel (PHDOC-03)
Submit a request for additional staffing support with this form. See a list of all available MRC volunteer categories.
Download
Capacity Assistance Forms
Assistance Capacity Report for Clinics (PHDOC-04)
Report facility hours, service expansion capabilities, or your organization’s ability to support additional services, if requested.
Download
Assistance Capacity Report for Surgery Centers (PHDOC-05)
Report facility hours, service expansion capabilities, or your organization’s ability to support additional services, if requested.
Download
Assistance Capacity Report for Skilled Nursing Facilities (SNFs) and Long-term Care Facilities (LTCFs) (PHDOC-06)
Report facility hours, service expansion capabilities, or your organization’s ability to support additional services, if requested.
Download
Patient Tracking Forms
HICS 255 Master Patient Evacuation Tracking Form
Download
HICS 260 Patient Evacuation Tracking Form
Download
Instructions & Exercise Forms
Instructions for use of PH DOC 01, 02, and 03:
Instructions
ICS 214 Unit Log
Document all of your facility’s response activities in the event of a disaster.
Download
Participant Critique Sheet
Complete this sheet after a drill or emergency preparedness exercise.
Download
Mobile Hospital Deployment
Mobile Hospital Setup Information
The Mobile Medical Hospital may be deployed in disasters, public health emergencies or disaster preparedness trainings. If you would like more information about the mobile hospital, please contact Brenda Brenner via email brenda.brenner@santacruzcounty.us.
CHAMPS Member Preparation
Utilize these templates and resources to ensure your organization has a plan in place to be a contributing member of the CHAMPS in a disaster or major emergency in Santa Cruz County. Click the download button for the relevant template, save it to your computer, and modify it to formulate your organization’s plan.
Hazards Vulnerability Analysis
The Hazards Vulnerability Analysis (HVA) provides a tool to identify hazards that may affect demand for the health care facility’s services or its ability to provide those services. A HVA is often the foundation to develop an Emergency Operations Plan (EOP).
HVA Template
Download
HVA Template Instructions
Download
HVA Definitions
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Use California Office of Emergency Services webpage to find specific hazards by address. Type in your facility address to learn the risks at that address and what you can do to mitigate those risks.
Get familiar with the Hazard Mitigation Plans for the City of Santa Cruz and for the County of Santa Cruz County.
Emergency Operations Plan
California Primary Care Association provides this template to develop your clinic’s Emergency Operation Plan (EOP).
Clinic
Download
Continuity of Operations Planning
A Continuity of Operations Plan (COOP) helps prepare organizations to maintain mission critical operations after any emergency or disaster.
CMS Rule
The purpose of the Centers for Medicaid and Medicare Emergency Services (CMS) Preparedness Rule is to establish national emergency preparedness requirements to ensure adequate planning for both natural and man-made disasters, and coordination with federal, state, tribal, regional and local emergency preparedness systems.
Presentation about the Rule
Download
Resources
Download
The CMS webpage provides resources for compliance with the Centers for Medicare & Medicaid Emergency Preparedness Rule.
The Health and Humans Services webpage provides links to resources that can help provider and suppliers comply.
Additional Links & Resources
HHS.gov - Get an overview of the national Hospital Preparedness Program, from which the HCC is modeled.