The Following Individuals Have Reviewed This Document

The Following Individuals Have Reviewed This Document

/ U of M PANDEMIC INFLUENZA PLAN
[DEPARTMENT / UNIT NAME]
TITLE PAGE
UNIVERSITY OF MANITOBA
PANDEMIC INFLUENZA PREPAREDNESS, RESPONSE, AND RECOVERY PLAN
[DEPARMENT / UNIT NAME]
Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8
/ TABLE OF CONTENTS
TABLE OF CONTENTS

Description

/ Section- Page
Table of Contents / i
Record of Distribution / 1
Revision Log / 2
Record of Sign-Off / 3
Faculty / Department Response Plan / 4
Purpose / 4-1
Coordinators / 4-1
Action Plan / 4-2
1. Pre-Pandemic / 4-#
2. Pandemic Warning / 4-#
3. Minor Impact / 4-#
4. Major Impact / 4-#
5. Shutdown / 4-#
6. Recovery / 4-#
Concluding Material / Attachments / Tools / Notes / 4-#
Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8 / i
/ RECORD OF DISTRIBUTION
BACKGROUND INFORMATION
Item Description:
File Number:
RECORD OF DISTRIBUTION
NAME (Please Print) / Program / Organization / Affiliation
Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8 / PAGE / OF
/ REVISION LOG
BACKGROUND INFORMATION
Description:
File Number:
MAINTENANCE LOG
Date / Revised by: / Page / Update / New / Action / Notes/ Remarks
Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8 / PAGE / OF
/ RECORD OF SIGNATURES
RECORD OF SIGNATURES

The following individuals have reviewed this document:

Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Name: / Phone:
Title: / Email:
Signature: / Date:
Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8 / PAGE / OF
/ U of M PANDEMIC INFLUENZA PREPAREDNESS, RESPONSE, and RECOVERY PLAN
[DEPARTMENT / UNIT NAME]
PURPOSE (Refer to Section 4.2 in the Guideline)

The purpose of the [Department / Unit] plan is:

  • Insert a bullet list if desired.

The institutional principles and planning assumptions established by the University of Manitoba Pandemic Planning Committee are documented in Section 1.0 Introduction of the Pandemic Planning Guideline.

COORDINATORS (Refer to Section 4.3 in the Guideline)

The personscoordinating pandemic planning within the [Department / Unit] are:

Name / Work Phone / Work Fax / Work Cell / Work Email / Home Phone / Home Cell / Home Email / Cottage
Last, First Name / 999-9999 / 999-9999 / 999-9999 / 999-9999 / 999-9999 / (999) 999-9999
ACTIONPLAN(Refer to Section 4.4and 4.5 in the Guideline)
1. PRE-PANDEMIC (WHO PHASE 1 & 2)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported(select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions(Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
2. PANDEMIC WARNING (WHO PHASE 3)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported (select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions (Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
3. MINOR IMPACT (WHO PHASE 4)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported (select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions (Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
4. MAJOR IMPACT (WHO PHASE 5 & 6)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported (select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions (Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
5. SHUTDOWN (WHO PHASE 5 & 6)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported (select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions (Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
6. RECOVERY (WHO Post-Pandemic Period)

Department / Unit Goals

  • insert

Institutional Goal(s) Supported (select all that apply) (Refer to Section 1.2 in the Guideline)

#1 / #2 / #3 / # 4 / # 5 / # 6

Actions (Refer to Section 4.5 and Appendix B of the Guideline)

Strategy / Action / Person(s) Responsible / Resources Required / Status

Additional Information (include policies, procedures, technical information or references / locations of this information here)

Item / Person(s) Responsible / Storage Location
CONCLUDING MATERIAL / ATTACHMENTS / TOOLS / NOTES

Terminology

For acronyms or technical terminology please provide definitions for inclusion in a master list to be kept in the overall university plan. A master list is maintained by the U of M Emergency Management Program under File No. 1.3.5.25.40.

Assumptions

Assumptions should be kept to a minimum - if you have an assumption validate it.

Contact Information

Phone numbers, email addresses and other contact information for individuals listed in this plan should be maintained in a single directory in the overall university plan (for ease of updating).

Printed: February 12, 2007
Revised: February 12, 2007 / UM Emergency Management Program
File No.: 1.3.5.9.2.5.8 / Page 1 of 8
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