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* 1. Today's Date

Date

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* 2. Type

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* 3. Loss of Access to Electronic Medical Record (Optional)

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* 4. Temporary Methods to Maintain Documentation

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* 5. Uploading Information into Electronic "Medical Records" when Access is restored and Achieved

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* 6. Loss of Administrative and/or Financial Data

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* 7. Need to Restore Lost Data

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* 8. Temporary Methods to Maintain Documentation in Place

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* 9. Restoring damaged or corrupted data successful

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* 10. Summary / Analysis of Continuity / Recovery Drill

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* 11. Were procedures in place to deal with loss effective?

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* 12. Is there a need for actions to be taken or the development of a Performance Improvement Plan?

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* 13. If yes, add suggestion Action Plan

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* 14. Are there indications for education / training for staff?

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* 15. Training Needs

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* 16. Names of Staff Involved in the Drill/Event

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* 17. Name of Drill/Event Coordinator

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