NW9 ESRD Emergency: Status Report Please report your facility's status/planned status and any impact that the event had on your facility.You can report for more than one facility. Please submit individual reporting forms for each facility. Question Title * 1. Your Name, Facility and Title Name: * Facility: * Title City/Town: County: Email Address: State Question Title * 2. Facility CCN # (#xx-XXXX) Question Title * 3. Date(s) reporting for (xx/xx/20xx) Question Title * 4. Please give us your facility status. Open Closed Altered Schedule (delayed open/early close) Monday Monday Open Monday Closed Monday Altered Schedule (delayed open/early close) Tuesday Tuesday Open Tuesday Closed Tuesday Altered Schedule (delayed open/early close) Wednesday Wednesday Open Wednesday Closed Wednesday Altered Schedule (delayed open/early close) Thursday Thursday Open Thursday Closed Thursday Altered Schedule (delayed open/early close) Friday Friday Open Friday Closed Friday Altered Schedule (delayed open/early close) Saturday Saturday Open Saturday Closed Saturday Altered Schedule (delayed open/early close) Sunday Sunday Open Sunday Closed Sunday Altered Schedule (delayed open/early close) Comments/Issues (Staff travel/patient transportation, electricity, water issues etc) Question Title * 5. Do you have any patients that you have not been in contact with? YES NO If YES please give total #, No PHI via internet. To send PHI, fax list of unaccounted for patients including SSN and DOB to the Network Question Title * 6. Is there anything that the Network can do for you to help your patients or facility? Done