WCMHPC Documents and Forms – Central and West Central Healthcare Preparedness Coalition

The Health Care Coalitions and Minnesota Department of Health Office of Emergency Preparedness and Response have worked together to create a Pediatric Surge Toolkit. The kit includes training videos, educational materials and templates for facilities to use to create the facility based Pediatric Surge plan. Please check out the site at: Pediatric Toolkit Link

WCMHPC documents and forms

Emergency Response Forms/Templates

Emergency Response Forms

Appendix 3.4.2 Resource Request, Receipt and Promissory Agreement

Appendix 3.5.1.2.3 Regional HICS 254 MNTrac Master Patient tracking form

Membership Forms

coalition membership documentation (FY2019)

MEMBERSHIP DOCUMENTATION – FOR FY2019 ALL SIGNATURES MUST BE RECOLLECTED….PLEASE SUBMIT TO SHAWN STOEN BY AUGUST 31, 2019

Coalition Membership Signatory Process – FY2019

Partner Agency Acknowledgement of Bylaws – FY2019 (for Emergency Management, volunteer organizations and non-health care agencies only)

WCMHPC Annual Signatures – FY2019 (for hospitals, long term care, public health and other health care facilities only)

FY2019 Reimbursement forms

FY2019 reimbursement documentation

WCMHPC Reimbursement form FY2019 HOSPITAL ONLY

FACILITY IN KIND REPORT – TRACKING TOOL