Emergency Status Report

Whether there is a winter storm approaching or a large disaster in your region, informing the Network of the impact to your facility and the plan for continuous patient care is critical. Please use this form to report to the Network and to CMS how the emergency event has affected your facility (e.g., power failure, storm damage). Of special concern is the safety and health of your staff and patients.

Only fill out form if your ability to care for your patients has been impacted.

Date of Report*

Dialysis Facitity Contact Information

CCN*

Facility Name*

Address*

City/Town*

State/Province*

ZIP/Postal Code*

Phone Number*

Primary Contact During Disaster

Name*

Title

Contact Phone Number*

Email Address*

Current Facility Operating Status

Status*

Select or enter value

Number and Status of Current Patients

Total Patient Census*

Number of patients with altered schedules*

0 if none

Number of unaccounted for patients*

0 if none

About the Event

Describe the "event"*

Select or enter value

Other

Status of the Event

Current Status*

Select or enter value

Status of the Facility

Facility Status*

Select or enter value

Other Status

Status of Patients Treatments

Patients are treating in current facility

Patient treatment schedules were adjusted

Patients were transferred to other locations

Please indicate if any of the following are needed

Generator

Potable Water

Medical Supplies

Fuel

Transportation

Security

Staffing

Other Need

Please, describe the plans to return to pre-emergency state

Details of Plan*

Describe the assistance provided by (or needed from) corporate, local, state or federal agencies

Details of Provided Assistance*

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Emergency Status Report

***Only fill out form if your ability to care for your patients has been impacted.***

Dialysis Facitity Contact Information

Primary Contact During Disaster

Current Facility Operating Status

Number and Status of Current Patients

About the Event

Status of the Event

Status of the Facility

Status of Patients Treatments

Please indicate if any of the following are needed

Please, describe the plans to return to pre-emergency state

Describe the assistance provided by (or needed from) corporate, local, state or federal agencies

Only fill out form if your ability to care for your patients has been impacted.