Auxillary Essential Elements of Information - Emergent

Facility Information

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Phone Number

Open (business as usual)

Open-limited (services are restricted)

Closed (facility closed)

Temporary space (using tents, mobile facility, or other alternate care space)

Unknown

Mixed Status (indicates more than one of the above apply)