Dialysis Facility Status Report

Changes in facility status due to emergency situations happen ...

Whether there is a winter storm approaching or a large disaster in your region, informing the Network of the impact to your facility and the plan for continuous patient care is critical. Please use this form to report to the Network and to CMS how the emergency event has affected your facility (e.g., power failure, storm damage). Of special concern is the safety and health of your staff and patients.

Question Title

* 1. Date of Report

Date:

Date

Tell us about your dialysis facility...

Question Title

* 2. What dialysis facility are you reporting on?

Facility Name

Facility Ownership

CCN (Medicare Provider Number)

Address

City/Town

State/Province

ZIP/Postal Code

County

Phone Number

Question Title

* 3. Facility Representative

Name

Title

Email address

Question Title

* 4. During the reported event, what is your facility's operating status? (Chose one)

Open

Closed

Altered

Question Title

* 5. Please enter the number of patients at your facility.

Total Patient Census

Number of patients affected by the event (e.g. altered schedules)

Number of unaccounted for patients

Tell us about the event...

Question Title

* 6. Describe the "event"? (Select all that apply)

Winter Storm/Blizzard/Ice Storm

Flood/External

Tornado

Earthquake

Water Contamination

Civil Disturbance

Pandemic/Quarantine

Other (please specify)

Question Title

* 7. The event... (Chose one)

is anticipated/expected (hasn't happened yet but we're preparing for it)

is in progress (happening now- as of date of this report)

has already occurred (we've responded to the event and returning to pre-event status)

Please provide event dates.

Question Title

* 8. What has the impact been on your facility? (Select all that apply)

No physical damage

Minor physical damage

Major physical damage

Building accessibility affected

Phone lines affected

Internet service affected

Electricity affected

Water supply affected

Facility Closure (please include in comment box the anticipated length of closure)

Other/Comment:

Question Title

* 9. What is happening with your patients? (Select all that apply)

All patients accounted for

Patient treatment schedules were adjusted

Patients were successfully transferred to other locations to receive treatment

There are patients that we could not reach

Comment:

Question Title

* 10. Please indicate if any of the following are needed.

	Yes	No
Generator	Generator Yes	Generator No
Potable Water	Potable Water Yes	Potable Water No
Supplies	Supplies Yes	Supplies No
Fuel	Fuel Yes	Fuel No
Transportation	Transportation Yes	Transportation No
Security	Security Yes	Security No
Staffing	Staffing Yes	Staffing No

Other (please specify)

Question Title

* 11. Please, describe the plans to return to pre-emergency state.

Question Title

* 12. Describe the assistance provided by (or needed from) corporate, local, state or federal agencies?

Thank you for informing the Network of your facility's current status. Please complete this form daily or contact the Network until your facility has returned to pre-emergency operations.