• MT Public Health Emergency Preparedness Technical Assistance Request

  • Format: (000) 000-0000.
  • What type of Technical Assistance is being requested? (Select all that apply)*
  • Outreach & Collaboration
  • Plans
  • Exercises
  • Training and Education
  • Access & Functional Needs
  • Strategic National Stockpile/CHEMPACK
  • Select specific exercise planning support needed:
  • Select specific staffing/role support needed for your exercise:
  • Select specific evaluation support needed:
  • Select specific review support needed:
  • Montana Healthcare Mutual Aid System (MHMAS)
  • What other assistance are you requesting?
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  • Do you plan to use This is a Test as a teambuilding activity? Or do you plan to use This is a Test to exercise your jurisdiction's POD plan?

  • This is a Test:
    If you plan to use This is a Test to exercise your jurisdictional POD plan please complete the information below.

    Number of players estimated to participate:*    
    *         *   *   *   
    Preferred dates of exercise (enter 2-3 date options):   *   
    Partners to be included:   *   
    Medicine or vaccine dispensing version?
       *   

    For jurisdictions using This is a Test to exercise their POD plan onsite facilitation will be offered based on each jurisdiction's needs.

  • This is a Test:
    If you plan to use This is a Test as a team-building activity, please complete the information below.

    Number of game set needed (based on 3-7 players for each set):*    
    *      *   *   *   
    Date game is needed by:   *   
    How long do you anticipate needing the game?      

    For jurisdictions using This is a Test for team-building, the MT PHEP section will ship the game and provide technical assistance prior to the event. No onsite facilitation will be provided.

  • PortaCount Equipment Loan Program


    Please read the FAQs and complete all of the requested information below.

    Program Frequently Asked Questions

    • There is NO cost to use this program.
    • Organizations may keep the PaC for up to 3 weeks. (Though every effort should be made to minimize the amount of time needed.)
    • This program is for fit testing the N95 disposable particulate respirator. Other respirators are not supported.
    • HPP will pay for the shipping to and the return of the PaC from the requesting organization. HPP WILL NOT ship to a PO Box. You must provide a valid physical shipping address below.
    • HPP can provide basic instruction on the use of the PaC via prerecorded video and one-on-one consultation by phone, email, or teleconference. Site visits should not be necessary. For questions, contact Jacob Brown at Jacob.Brown@Mt.Gov.
    • This is a loan of the PortaCount (PaC) equipment, accessories, and testing supplies only. The Hospital Preparedness Program (HPP) WILL NOT conduct the fit testing or provide N95 respirators.


    *   *   *      *   *   *   
    How many personnel do you plan on fit-testing? *
    What date will you begin fit-testing?*
    How many days do you expect/estimate you will be conducting fit-testing?  *   

  • What kind of volunteer is needed? *
    Duties volunteer will be performing *         
    Pay rate being offered for volunteer * 
    Volunteer Work Hours *      
    Lodging provided for volunteer * 
    Per diem provided for volunteer *
    Milage reimbursement provided for volunteer * 
    Can the requesting jurisdiction pay for this request? * 
    Point of Contact for requesting jurisdiction * 

  • Should be Empty: