What is the activity you are completing this form for?
Is this a direct service to an individual, family, or community members?
* must provide value
Yes
No
Unsure
Is this activity mandated for governmental public health to carry out by state or federal law OR is governmental public health the only or primary provider statewide?
* must provide value
Yes
No
Unsure
Which of the following best describes the activity?
Hover over each option to learn more.
* must provide value
Unsure
Which area is the direct service to an individual related to:
Communicable Disease Control
Chronic Disease and Injury Prevention
Environmental Public Health
Maternal, Child, and Family Health
Access to and Linkage with Clinical Care
Unsure
Which of the following does this cross-cutting activity best reflect?
Assessment and surveillance
Communications
Community Partnership Development
Equity
Accountability and Performance Management
Organizational Competencies
Policy Development and Support
Emergency Preparedness and Response
Unsure
Which of the following area does the activity best fit into?
Communicable Disease Control
Chronic Disease and Injury Prevention
Environmental Public Health
Maternal, Child, and Family Health
Access to and Linkage with Care
None
Select one category that best aligns with the activity.
Provide timely, relevant, and accurate information to partners and the public on communicable diseases and their control.
Develop a prevention plan for communicable disease control in collaboration with community partners.
Identify and respond to communicable disease outbreaks for notifiable conditions in accordance with local, state, and national requirements.
Support the recognition of outbreaks and other events of public health significance.
Coordinate, integrate, align, and address funding opportunities for statutorily required communicable disease programs and activities.
None of the above
Select one category that best aligns with the activity.
Provide timely, relevant, and accurate information to partners and the public on population health trends related to chronic disease and injury prevention.
Develop a prevention plan for chronic disease and injury prevention in collaboration with community partners.
Coordinate, integrate, address funding opportunities, and align chronic disease and injury prevention programs and initiatives.
Work actively with statewide and community partners to implement population-based strategies to increase protective factors and reduce modifiable risk factors for chronic disease and injury.
None of the above
Select one category that best aligns with the activity.
Provide timely, relevant, and accurate information to partners and the public on environmental public health threats and health impacts.
Develop a prevention plan for environmental public health in collaboration with partners.
Conduct mandated environmental public health activities and oversight to protect the public from hazards in accordance with local, state, and federal laws and regulations.
Identify and address radiation, chemical, and other public health hazards related to environmental factors in accordance with local, state, and federal laws and regulations.
Coordinate, integrate, align, and address funding opportunities for environmental public health work across public health programs and activities, and partner agencies.
None of the above
Select one category that best aligns with the activity.
Provide complete, accurate, and locally relevant data and information as available to partners and the public on maternal, child, and family health trends.
Develop a prevention plan for maternal, child, and family health in collaboration with community partners.
Identify, disseminate, and promote emerging and evidence-based practices and programs which promote lifelong health and wellbeing.
Maintain and utilize newborn screening and identification of infants with birth defects to support and coordinate follow up.
Coordinate, integrate, align, and address funding opportunities for maternal, child, and family health programs and activities.
None of the above
Select one category that best aligns with the activity.
Provide timely, complete, and locally relevant information on availability of or barriers to health care (including behavioral health); share information with the community and health care system.
Assure licensed health care facilities and providers comply with laws and rules as appropriate.
Collaborate with national and statewide groups, local providers, and health care partners to develop plans and address funding opportunities for increasing access to patient-centered medical homes, quality health care, and high priority policy initiatives.
None of the above
Is this activity providing service to an individual, family, or community members?
Examples include, but are not limited to:
1, Case management
2, Discharge planning
3, Transportation of individuals to oral, mental, or other clinical health visits
4, Distributing Narcan to individuals
5, Health screenings at health fairs
6, Medical check-ups
7, Mental health counseling
8, Disease treatment
9, Foot care clinics
10, Providing immunizations
11, Distributing equipment to individuals through Child Passenger Safety for Child Seats
12, Education classes to individuals, families, or community members
13, Distributing items to individuals, families, or community members
Yes
No
Unsure
Is the activity population-based, focused on disease prevention, protection, and health promotion?
Population-based approaches, programs, or interventions aim to improve health outcomes for entire groups rather than individuals, address the collective conditions and systems that influence health outcomes, and involve collaboration and use of data to inform action.
Yes
No
Unsure
Is this activity mandated by state or federal law for governmental public health to provide or carry out?
Yes
No
Unsure
Is governmental public health the only or primary provider statewide?
Yes
No
Unsure
Based on your response, this activity fits under the foundational capability "assessment and surveillance". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "communications". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "community partnership development". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "equity". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "accountability and performance management". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "organizational competencies". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "policy development and support". For annual reporting, report under "All capabilities except EPR"
Based on your response, this activity fits under the foundational capability "emergency preparedness and response". For annual reporting, report under "Emergency Preparedness and Response".
Based on your response, this activity is "foundational", under the area "Communicable Disease Control".
Based on your response, this activity is "foundational", under the area "Chronic Disease and Injury Prevention".
Based on your response, this activity is "foundational", under the area "Environmental Public Health".
Based on your response, this activity is "foundational", under the area "Maternal, Child, and Family Health".
Based on your response, this activity is "foundational", under the area "Access to and Linkage with Clinical Care".
Based on your response, the activity is community-specific. To help you determine which area it aligns with, review with relevant agency staff and leadership and use best judgement.
Based on your responses, it cannot be determined if the activity is foundational or community specific. Review definitions of foundational responsibilities with relevant agency staff and leadership and use best judgement.