Exit this survey

Complete report when requested to do so through email or an overhead announcement.

Submit through: www.surveymonkey.com/s/CSHCSTATREP, fax (315) 462-3776, deliver to the command center, located off of the main lobby, behind the telephone operator

* 1. Are there any urgent life safety issues?

* 3. Person currently managing department:

* 4. Report Prepared by:

5. Date and Time Report Prepared

* 6. Phone number of person preparing (in format 3154620305):

7. List the number of staff with any of the following capabilities or credentials who are available in your department currently (list each person only once):

8. How many of these resources are available for deployment, if needed?

9. Bed Stats - please enter number of:

10. List the number of current patients on your unit that fit each of the evacuation mobility levels listed.

11. List the number of current patients on your unit that have the following special needs:

12. Status of major technology uses in your department:

  Functioning Not Functioning Not Applicable
Lighting
Emergency Power
Telephones
Fax
Radios
Medical Gases
Medical Vacuum
Computers/E-mail
Internet
Wander Guard
Nurse Call
Electronic Door Security

13. Has the event had an impact on your unit/department?

T