MT Public Health Emergency Preparedness Technical Assistance Request

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 anticipated to participate:Number of players*    
Exercise Location (Street Address)*         City*   State*   Zip*   
Preferred dates of exercise (enter 2-3 date options):   Preferred dates of exercise*   
Partners to be included:   Partners to be included*   

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 an educational and/or teambuilding event in your jurisdiction please complete the information below.

Number of game set needed (based on 3-7 players for each set):Number of games*    
Shipping Address(Street Address)*      City*   State*   Zip*   
Date game is needed by:   Date needed by*   
How long do you anticipate needing the game?   Anticipated length   

For jurisdictions using This is a Test for educational and/or teambuilding events, the MT PHEP section will ship the game and provide technical assistance prior to the event. No onsite facilitation will be provided.

HPP 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.

Facility Name*   Point of Contact Name (Attn:)*   Shipping Address*      City*   State*   Zip*   
How many personnel do you plan on fit-testing? Number of personnel needing fit-testing*
What date will you begin fit-testing?date to begin fit-testing*
How many days do you expect/estimate you will be conducting fit-testing?  Number of days conducting fit-testing*