SurveyMonkey Powered Online Survey

1.Your info:

Name:

Health Center:

City/Town:

Email Address:

2.Which region is this site in? For those with multiple sites, please feel free to check all regions you are reporting on.
(Unsure what region you are in, visit: https://matracking.ehs.state.ma.us/hmcc_regions/hmcc_regions.html)

5.Have you communicated any changes in operations to anyone else? (Skip if not applicable.)
Please note that in order to reduce your reporting burden, the League will use the information collected in this survey to inform regional Health & Medical Coordinating Coalitions (HMCCs) and MDPH Office of Preparedness and Emergency Management (OPEM) of your operational status, as appropriate.

Massachusetts Department of Public Health (MDPH)

Local Board of Health / Local Health Officer

Regional Health & Medical Coordinating Coalition (HMCC)

Affiliated Hospitals

Vendors

Contracted Services (such as pharmacies, etc.)

HRSA point of contact

Local Emergency Management Director

Other (please specify):

6.Do you need any assistance, from the League or other agencies? If yes, we will contact you directly.

Yes

No

7.What are your top priorities at this time?

Safe access to facility

Rescheduling of patients (from in-clinic to telehealth)

Rescheduling of patients (in-clinic appointments only)

Safety of staff and patients onsite

Returning to normal operations

Reduction of potential losses (facility, pharmaceuticals / vaccines, revenue, etc.)

Other (please specify)

8.As a precaution, please provide us with your health center's emergency contact information (if different from above):

Name:

Email Address:

Phone Number:

9.Please share any other information that you feel is important for us to know. Thank you.

Emergency Management - CHC Operational Status Reporting - 2022-present