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Distributed by the IPRO QIN-QIO Nursing Home Team (IPRO QIN-QIO). 

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* 1. Name of Nursing Home
If filling out for multiple facilities, please list the name and corresponding CCN number for each facility.

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* 2. State (This nursing home is in the State of ...)

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* 3. CMS Certification Number (CCN)
If you do not know your facility CCN Number, please use this tool to find it: CCN Lookup Tool

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* 4. Today's Date

Date

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* 5. Please provide your full name.

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* 6. Email Address

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* 7. Please provide a telephone number where you can be reached with any questions about your submission.

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* 8. What is the job title of the person who oversees the Emergency Preparedness Program (EPP)?

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* 9. Emergency Preparedness Team
Does your Emergency Preparedness Team include at least one member from each department of your facility, at least one member from each shift, at least one resident, and at least one family member?

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