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

* 1. Your Name, Facility and Title

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

* 3. Please list date(s) reporting for

* 4. Please give us your facility status  (Single Answer: Open, Altered or Closed)

* 5. Please explain event and mitigation plans

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

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