Incident & Impact Alert

During emergent incidents and/or disaster situations, receiving timely health center operational status information is crucial for Community Care Network of Kansas (Community Care) to connect you with disaster relief organizations and other resources to ensure continuity of care.


Information collected will be used to support during such incidents and will help inform Community Care advocacy efforts and training/technical assistance needs.


Please reach out to Community Care's emergency management lead, Alice Weingartner at aweingartner@communitycareks.org for additional support, questions, or concerns.

 

Name of person submitting form

 

Title of person submitting form

 

Email of person submitting form

 
 
 

Begin typing name of organization, then select from list. if health center is not listed, please select OTHER

 

Begin typing name of site, then select from list. If site is not listed, please select OTHER

 

Select the type of incident(s) being reported

 

check box if this incident/event is currently still active or ongoing

 

Indicate the current operational status of the site impacted

 

Indicate what services have been impacted by the incident being reported

 

If incident has impacted staffing level, indicate the current percentage that is operating

 

What are your top priorities at this time?

 
 

Indicate the type of support that is needed at this time and elaborate in the next field.

 
 

Please indicate if you require additional support and would like to be connected to partner emergency relief organizations. This may include pharmaceuticals, medical supplies, and/or emergency funds.

 

Please indicate if you would like to request a site visit from Community Care staff to highlight damage/impact/needs

 
 

If different from person submitting form

 

If different from person submitting form

 

If different from person submitting form

 
 

Please share any additional information you feel is important for Community Care to be aware of