LPCA After Event Emergency Damage Survey 2024-2025

LPCA After Event Emergency Damage Survey 2024-2025

Is this an initial report or update?

Select

Today's Date

Event

If Other Event, Explain

Health Center Name

Select

Health Center Site Address

Parish(es) of affected site(s)

Select

Health Center Telephone Number

Your Name

Best Way to Reach You

Select

Operational Status of FQHC Sites

Select

How many sites are affected?

Select

Which sites are affected (list site names)?

Reasons for Site Closures

Your Email Address

Estimated Date to Returning to Full Operations

Are any services offered through closed sites?

Select or enter value

Impact to Service Delivery of HRSA programs

Select or enter value

Impact to any COVID-19 Specific Programs

Select

Need help from DirectRelief, Americares, etc?

Select or enter value

What Supplies Do You Need?

Do You Have Staff to Share?

Select

Do You Have Supplies to Share?

Select

Will You Treat Patients from Other Affected FQHCs?

Select

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