Please report your facility's planned status.
You can report for more than one facility please submit individual reporting forms for each facility.
Your Name, Facility and Title

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* 1. Your Name, Facility and Title

Facility CCN # (#xx-XXXX)

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* 2. Facility CCN # (#xx-XXXX)

Scheduling Impact

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* 3. Scheduling Impact

Date / Time
Please give us your facility status for date listed above

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* 4. Please give us your facility status for date listed above

  Open Delayed Open Closed Closed Early
Day Reporting
Do you have any patients that you have not been in contact with?

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* 5. Do you have any patients that you have not been in contact with?

Is there anything that the Network can do for you to help your patients or facility?

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* 6. Is there anything that the Network can do for you to help your patients or facility?

T