NW1 ESRD Emergency: Schedule Change

Please report your facility's planned status.
You can report for more than one facility please submit individual reporting forms for each facility.

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* 1. Your Name, Facility and Title

Name: *

Facility: *

Title

City/Town:

Email Address:

State

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

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

Day 1

Day 2

Day 3

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

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

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

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* 7. Please explain event and mitigation plans.

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

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

YES

NO

If YES please give total #, No PHI via internet. To send PHI, fax list of unaccounted for patients including SSN and DOB to the Network