Question Title

1. Today's Date (Required.)

Date

Question Title

2. Type (Required.)

Question Title

3. Loss of Access to Electronic Medical Record (Optional) (Required.)

Question Title

4. Temporary Methods to Maintain Documentation (Required.)

Question Title

5. Uploading Information into Electronic "Medical Records" when Access is restored and Achieved (Required.)

Question Title

6. Loss of Administrative and/or Financial Data (Required.)

Question Title

7. Need to Restore Lost Data (Required.)

Question Title

8. Temporary Methods to Maintain Documentation in Place (Required.)

Question Title

9. Restoring damaged or corrupted data successful (Required.)

Question Title

10. Summary / Analysis of Continuity / Recovery Drill (Required.)

Question Title

11. Were procedures in place to deal with loss effective? (Required.)

Question Title

12. Is there a need for actions to be taken or the development of a Performance Improvement Plan? (Required.)

Question Title

13. If yes, add suggestion Action Plan

Question Title

14. Are there indications for education / training for staff? (Required.)

Question Title

15. Training Needs (Required.)

Question Title

16. Names of Staff Involved in the Drill/Event (Required.)

Question Title

17. Name of Drill/Event Coordinator (Required.)

T