Please report your facility's planned status.
You can report for more than one facility please submit individual reporting forms for each facility.
Your Name, Facility and Title

Question Title

* 1. Your Name, Facility and Title

Facility 6-Digit CMS Certification Number (CCN)

Question Title

* 2. Facility 6-Digit CMS Certification Number (CCN)

Please list date(s) for which you are reporting operational status.

Question Title

* 3. Please list date(s) for which you are reporting operational status.

Day 1: Please specify facility operational status  (Single Answer: Open, Altered or Closed)

Question Title

* 4. Day 1: Please specify facility operational status  (Single Answer: Open, Altered or Closed)

Day 2: Please specify facility operational status (Single Answer: Open, Altered or Closed)

Question Title

* 5. Day 2: Please specify facility operational status (Single Answer: Open, Altered or Closed)

Day 3: Please specify facility operational status (Single Answer: Open, Altered or Closed)

Question Title

* 6. Day 3: Please specify facility operational status (Single Answer: Open, Altered or Closed)

Please explain event and mitigation plans.

Question Title

* 7. Please explain event and mitigation plans.

Is there anything that the Network can do to help your patients or facility staff?

Question Title

* 8. Is there anything that the Network can do to help your patients or facility staff?

Do you have any patients that you have not been in contact with?

Question Title

* 9. Do you have any patients that you have not been in contact with?

T