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?

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