Please report your facility's status/planned status and any impact that the event had on your facility.
You can report for more than one facility.  Please submit individual reporting forms for each facility.
Your Name, Facility and Title

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* 1. Your Name, Facility and Title

Facility CCN # (#xx-XXXX)

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* 2. Facility CCN # (#xx-XXXX)

Date(s) reporting for (xx/xx/20xx)

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* 3. Date(s) reporting for (xx/xx/20xx)

Please give us your facility status.

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* 4. Please give us your facility status.

  Open Closed Altered Schedule (delayed open/early close)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you have any patients that you have not been in contact with?

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

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

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* 6. Is there anything that the Network can do for you to help your patients or facility?

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