Fillable Request for the Temporary Reassignment of State, Tribal, (Assistant Secretary for Preparedness and Response)

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Request for the Temporary Reassignment of State, Tribal, (Assistant Secretary for Preparedness and Response)

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BROWSE ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE (DC) FORMS

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Request for the Temporary Reassignment of State, Tribal, and
Local Personnel During a Public Health Emergency
Declared by the HHS Secretary
CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the
data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE,
MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).
Form Approved
OMB No. 0920-0879
Expiration Date 03/31/2018
Section 319(e) of the Public Health Service (PHS) Act authorizes states and tribes to request the temporary
reassignment of state, tribal, or local public health department or agency personnel funded under programs
authorized by the PHS Act when the Secretary of the Department of Health and Human Services (HHS) has
declared a public health emergency. The following reassignment conditions apply: reassignment must be
voluntary; locations for reassignment must be covered under the public health emergency; and any
reassignment over 30 days must be reauthorized.
Instructions: The state governor, tribal leader, or designee must complete this form and submit it to
TemporaryReassignment@hhs.gov. In the case of submission by a designee, a copy of the designation must be
included. Please note that reassignments are not authorized until HHS approval is received.
State or Tribal Locality: Date of Request:
Requesting Official, including name and title:
Contact Information, including email address and phone number:
Type of Request:
___ New
___ Extension
1.
Identify the public health emergency declared by the HHS Secretary. Include the official
date and titel
o
f the emergency as declared.
2. Identify the program applicable to the request and identify the authorizing HHS Operating or
Staff Division. Also include an approximate number of personnel eligible to volunteer for
reassignment.
Program: HHS Agency: Number of Personnel Eligible:
3
. Describe the activities that will be conducted by the reassigned personnel and why the particular
program was selected for co
nsideration. Also include the impact on the ability of the program to
meet the original mission and any budgetary impact.
Form Approved
OMB No. 0920-0879
Expiration Date 03/31/2018
4. Describe the impact that the temporary reassignment will have on the base program.
5. I assure the following:
The reassignment will last no longer than 30 days or until the HHS Secretary determines that
the public health emergency no longer exists, whichever comes first.
The public health emergency is in the geographic area of the state or Indian tribe.
The current public health workforce cannot adequately and appropriately address the emergency.
The public health emergency would be addressed more efficiently and effectively through the
temporary reassignment of state or local personnel.
The reassignment is consistent with the jurisdiction's all-hazards public health preparedness and
emergency response plan required under section 319C-1 of the PHS Act.
Unless otherwise provided under the laws or regulations of the state or Indian tribe, personnel
have the opportunity to volunteer for temporary reassignment and are not required to agree to a
temporary reassignment.
Within 120 days of the end
of the emergency
or
the end
of
the temporary
reassign
ment
authorization,
the
state
or
Indian tribe
will
submit to
the
HHS Secretary
(through
the Office of the Assistant Secretary for
Preparedness and Response) a report
outlining
the effect
the
reassignment had
on
each
p
rogram.
The after action report must include:
-The number of personnel reassigned from each program;
-The amount of funds used to support the reassigned personnel;
- Actual impact the temporary reassignment had on the programs, both positive and adverse;
- How medical surge capacity was improved through reassignment (if applicable);
- How the reassignment of personnel improved operational efficiencies; and,
- How the reassignment assisted the state or Indian tribe in responding to or addressing the public health
emergency.
Printed Name of Authorized Official:
Signature of Authorized Official: Date:
Form Approved
OMB No. 0920-0879
Expiration Date 03/31/2018
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Request for the Temporary Reassignment of State, Tribal, (Assistant Secretary for Preparedness and Response)

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Completed 19 July 2020

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