Please report facility status.  You can report for more than one facility by submitting individual reporting forms for each facility.

* 1. Your Name, Facility and Title

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

* 3. What is your current patient census?

* 4. Please list date(s) reporting for

* 5. Have you notified the State Department of Health (NYPORTS)?

* 6. Please report your facility status:

* 7. Please explain event and mitigation plans

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

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