AzCHER Membership Participation Agreement

Participation Agreement for Member Engagement

The Arizona Coalition for Healthcare Emergency Response, hereafter referred to as AzCHER, is a statewide coalition of healthcare delivery organizations and their emergency preparedness partners maintaining the purpose of promoting individual facility and systemic resilience to disasters and/or large-scale emergencies affecting the healthcare sector in Arizona. The coalition serves all 15 counties of the state and welcomes the membership of any entity that supports AzCHER’s primary goal of enhancing coordination, cooperation, and communication pertaining to emergency prevention, preparedness, mitigation, response, and recovery.

This Participation Agreement is a voluntary and non-binding agreement to aid and support each other in the event of a disaster or large-scale emergency among:

Healthcare provider organizations

Hospitals / Acute Care
Long-term Care
Behavioral Healthcare
Ambulatory Care, such as ESRD clinics and ambulatory surgery centers
Community Health Centers
Other Providers

Critical healthcare collaborators and Core Members

Emergency Medical Services (EMS) / Medical Transport / First Responders
Public Health Agencies / PHEP Partners
Emergency Management Agencies

Supporting organizations (examples only)

Nonprofits / NGOs
Power and Communications Companies
Supply Chain (including equipment and pharmaceutical distributors)
Blood banks
Medical Laboratories
Organ Donor Networks

While participation in the coalition (i.e., being a “Partner”) does not require the submission of a signed Participation Agreement, membership (i.e., being a “Member”) does require such.

AzCHER members are organizations, not individuals, and may have multiple facilities or sites. The member entity is, for example, a health system, with each licensed hospital, surgery center, and other site where healthcare is provided listed as a facility. Other collaborators and supporting organizations should provide information on the primary site or headquarters and may list additional sites as facilities.

Each AzCHER member organization must provide a key contact person, the Designated Member Representative (DMR), who will serve as the primary contact with whom coalition staff will communicate on all matters pertaining to the member organization. Such matters may include but are not limited to coalition response functions such as notification of member EOC activation and the provision of requested status data (also known as essential elements of information). The DMR will be responsible for submitting survey responses (or distributing surveys to the appropriate organizational respondents), providing updated member data, and distributing relevant information to co-workers on behalf of the member entity. Additional contact persons listed in the database will receive general communications, such as Arizona Health Alert Network (AzHAN) alerts and newsletters. Any and all member representatives - not just the DMR - are invited to attend coalition events, such as General Body meetings and community-based exercises.

AzCHER Partner Benefits:

Networking / Building Professional Relationships
Information Sharing
Attend Regional General Body Meetings

AzCHER Member Benefits:

Voting on Coalition Matters
Opportunities to Participate in committees and work groups to develop community-wide assessments, plans, and exercises
Access to AzCHER-Connect Member Database
Access to AzCHER’s file sharing and group communications tool, BaseCamp
Training Opportunities
Exercise Participation (Exceptions can be made on a case-by-case basis, depending on the needs of the exercise and of members.)
Eligibility for Coalition Funds, if/when they are available

AzCHER Member Responsibilities:

Attend Regional General Body Meetings
Respond to requests for information, such as Coalition Hazard Vulnerability Assessment (CHVA) and inventory surveys
Update AzCHER-Connect with up-to-date information, such as changes in key contacts
Participate in Coalition Exercises, ranging from Arizona Health Alert Network (AzHAN) communication drills to statewide full-scale exercises, to the best of the member’s ability
Participate in the sharing of information that will lead to the region’s optimal emergency preparedness and response capabilities in a manner that 1) is in alignment with the member organization’s policies and procedures; 2) does not present a conflict of interest to the member organization; and 3) is not proprietarily protected
Participate in other various and miscellaneous ways, such as in providing a venue for coalition meetings or engaging in Functional Work Groups, as able
Maintain familiarity with the coalition’s emergency plans
Notify coalition staff of member exercises that are open to the community
Notify the coalition when the member’s Emergency Operations Center (EOC) is activated by contacting the member’s regional manager or, in an emergency that requires coalition support, calling 602-264-2930

To be eligible for additional benefits, such as Coalition Funds (if/when they are available), Members are Encouraged but not Required to:

Be registered as a closed POD with their local public health jurisdiction
Regularly attend General Body meetings (at least 50% of meetings in a 12-month period)
Regularly update EMResource (hospitals and some long-term care facilities only)
Have an executed Memorandum of Agreement with the National Disaster Medical System (NDMS) (hospitals only)
Have an executed Memorandum of Understanding with other members of the coalition (AzCHER MOU)
Share member inventory in the coalition’s inventory management tool

This version (Version 1: 2020) of the AzCHER Participation Agreement supersedes all previous regional membership documents. Furthermore, this Participation Agreement is subject to and incorporates the Terms of Use of the member database, AzCHER-Connect.

Nothing in this Participation Agreement is legally binding upon its signatories or their organizations. Any participation, including the degree of participation, with respect to this Agreement is strictly voluntary on the part of the participating organization.

Any signatory to this Participation Agreement may withdraw the organization’s membership by providing 30 days’ written notice to the coalition administrator at 2800 N. Central Avenue, Suite 1450, Phoenix, Arizona 85004.

A separate policy regarding eligibility, access to, and reporting on Coalition Funds shall be posted on the coalition’s website (www.azcher.org) when such funds are available.

v.1: 2020

AzCHER New Member Form

Form Errors:
Organization Details
Organization Name* (Please include full name)	Organization name
DBA/FKA	Doing business as
Primary Phone	Primary phone number
Website	Website address
Region	North Northern region Central Central region South Southern region West Western region Other Other region
Primary Facility
Facility Type*	select dropdown for facility type
Licensure Type*	select dropdown for licensure type Definitions
Facility Name*	Facility name
Street Address*	The physical address of the facility (No P.O.Box) Street address
Street Address #2	Secondary street address
City*	City
State*	select state
County*	select county
Region	select region
Zip Code	Zip code
EOC#	Emergency operations contact number
Primary Contact
First Name*	First Name
Last Name*	Last Name
Professional Title*	Professional title
Office Phone*	Office Phone
Cell Phone	Cell Phone
Email*	Email address Notification Check for email notifications
Password*	Password
Participation Agreement Participation Agreement for Member Engagement The Arizona Coalition for Healthcare Emergency Response, hereafter referred to as AzCHER, is a statewide coalition of healthcare delivery organizations and their emergency preparedness partners maintaining the purpose of promoting individual facility and systemic resilience to disasters and/or large-scale emergencies affecting the healthcare sector in Arizona. The coalition serves all 15 counties of the state and welcomes the membership of any entity that supports AzCHER’s primary goal of enhancing coordination, cooperation, and communication pertaining to emergency prevention, preparedness, mitigation, response, and recovery. This Participation Agreement is a voluntary and non-binding agreement to aid and support each other in the event of a disaster or large-scale emergency among: Healthcare provider organizations Hospitals / Acute Care Long-term Care Behavioral Healthcare Ambulatory Care, such as ESRD clinics and ambulatory surgery centers Community Health Centers Other Providers Critical healthcare collaborators and Core Members Emergency Medical Services (EMS) / Medical Transport / First Responders Public Health Agencies / PHEP Partners Emergency Management Agencies Supporting organizations (examples only) Nonprofits / NGOs Power and Communications Companies Supply Chain (including equipment and pharmaceutical distributors) Blood banks Medical Laboratories Organ Donor Networks While participation in the coalition (i.e., being a “Partner”) does not require the submission of a signed Participation Agreement, membership (i.e., being a “Member”) does require such. AzCHER members are organizations, not individuals, and may have multiple facilities or sites. The member entity is, for example, a health system, with each licensed hospital, surgery center, and other site where healthcare is provided listed as a facility. Other collaborators and supporting organizations should provide information on the primary site or headquarters and may list additional sites as facilities. Each AzCHER member organization must provide a key contact person, the Designated Member Representative (DMR), who will serve as the primary contact with whom coalition staff will communicate on all matters pertaining to the member organization. Such matters may include but are not limited to coalition response functions such as notification of member EOC activation and the provision of requested status data (also known as essential elements of information). The DMR will be responsible for submitting survey responses (or distributing surveys to the appropriate organizational respondents), providing updated member data, and distributing relevant information to co-workers on behalf of the member entity. Additional contact persons listed in the database will receive general communications, such as Arizona Health Alert Network (AzHAN) alerts and newsletters. Any and all member representatives - not just the DMR - are invited to attend coalition events, such as General Body meetings and community-based exercises. AzCHER Partner Benefits: Networking / Building Professional Relationships Information Sharing Attend Regional General Body Meetings AzCHER Member Benefits: Voting on Coalition Matters Opportunities to Participate in committees and work groups to develop community-wide assessments, plans, and exercises Access to AzCHER-Connect Member Database Access to AzCHER’s file sharing and group communications tool, BaseCamp Training Opportunities Exercise Participation (Exceptions can be made on a case-by-case basis, depending on the needs of the exercise and of members.) Eligibility for Coalition Funds, if/when they are available AzCHER Member Responsibilities: Attend Regional General Body Meetings Respond to requests for information, such as Coalition Hazard Vulnerability Assessment (CHVA) and inventory surveys Update AzCHER-Connect with up-to-date information, such as changes in key contacts Participate in Coalition Exercises, ranging from Arizona Health Alert Network (AzHAN) communication drills to statewide full-scale exercises, to the best of the member’s ability Participate in the sharing of information that will lead to the region’s optimal emergency preparedness and response capabilities in a manner that 1) is in alignment with the member organization’s policies and procedures; 2) does not present a conflict of interest to the member organization; and 3) is not proprietarily protected Participate in other various and miscellaneous ways, such as in providing a venue for coalition meetings or engaging in Functional Work Groups, as able Maintain familiarity with the coalition’s emergency plans Notify coalition staff of member exercises that are open to the community Notify the coalition when the member’s Emergency Operations Center (EOC) is activated by contacting the member’s regional manager or, in an emergency that requires coalition support, calling 602-264-2930 To be eligible for additional benefits, such as Coalition Funds (if/when they are available), Members are Encouraged but not Required to: Be registered as a closed POD with their local public health jurisdiction Regularly attend General Body meetings (at least 50% of meetings in a 12-month period) Regularly update EMResource (hospitals and some long-term care facilities only) Have an executed Memorandum of Agreement with the National Disaster Medical System (NDMS) (hospitals only) Have an executed Memorandum of Understanding with other members of the coalition (AzCHER MOU) Share member inventory in the coalition’s inventory management tool This version (Version 1: 2020) of the AzCHER Participation Agreement supersedes all previous regional membership documents. Furthermore, this Participation Agreement is subject to and incorporates the Terms of Use of the member database, AzCHER-Connect. Nothing in this Participation Agreement is legally binding upon its signatories or their organizations. Any participation, including the degree of participation, with respect to this Agreement is strictly voluntary on the part of the participating organization. Any signatory to this Participation Agreement may withdraw the organization’s membership by providing 30 days’ written notice to the coalition administrator at 2800 N. Central Avenue, Suite 1450, Phoenix, Arizona 85004. A separate policy regarding eligibility, access to, and reporting on Coalition Funds shall be posted on the coalition’s website (www.azcher.org) when such funds are available. v.1: 2020 I agree on behalf of the organization Participation agreement acceptance

AzCHER New Member Form

Form Errors:

Organization Details

Primary Facility

Primary Contact

Participation Agreement for Member Engagement