LPCA After Event Emergency Damage Survey 2024-2025

Is this an initial report or update?

Today's Date

mm/dd/yyyy

Event

If Other Event, Explain

Health Center Name

Health Center Site Address

Parish(es) of affected site(s)

Health Center Telephone Number

Your Name

Best Way to Reach You

Operational Status of FQHC Sites

How many sites are affected?

Which sites are affected (list site names)?

Reasons for Site Closures

Your Email Address

Estimated Date to Returning to Full Operations

mm/dd/yyyy

Are any services offered through closed sites?

Impact to Service Delivery of HRSA programs

Impact to any COVID-19 Specific Programs

Need help from DirectRelief, Americares, etc?

What Supplies Do You Need?

Do You Have Staff to Share?

Do You Have Supplies to Share?

Will You Treat Patients from Other Affected FQHCs?

Comments

Please list sites that are closed/limited

Which sites are still affected (List Names)?

Your Phone Number

If you chose OTHER, enter name of health center he

Send me a copy of my responses