NW2 Emergency Reporting: Schedule Change

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

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* 1. Your Name, Facility and Title

Name: *

Facility: *

Title

City/Town:

Email Address:

Cell Phone #

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* 2. Facility CCN # (#33-XXXX)

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* 3. What is your current patient census?

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* 4. What type of event are you reporting for?

Snow/Ice

Water Issues (RO etc.)

Power Loss

Wind Storm/Flooding

Positive Cultures

Other (please describe below)

Other (please specify)

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* 5. Please list date(s) reporting for

Day 1

Day 2

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

Yes

If No, why?

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* 7. Please report your facility status:

Open

Closed

Altered (Open Late/Closed Early)

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* 8. Please explain event and mitigation plans

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

YES

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

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* 1. Your Name, Facility and Title

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* 2. Facility CCN # (#33-XXXX)

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* 3. What is your current patient census?

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* 4. What type of event are you reporting for?

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* 5. Please list date(s) reporting for

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

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* 7. Please report your facility status:

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* 8. Please explain event and mitigation plans

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

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