Incident & Impact Alert

Incident & Impact Alert

During emergent incidents and/or disaster situations, receiving timely health center operational status information is crucial for CPCA 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 CPCA advocacy efforts and training/technical assistance needs.

Please reach out to CPCA’s emergency management lead, Ivan Prado at iprado@cpca.org for additional support, questions, or concerns.

Name

Name of person submitting form

Title

Title of person submitting form

Email of person submitting form

Submission Type

Select

Health Center Organization

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

Select or enter value

OTHER Health Center Organization

If health center was not listed above, please add here

Site Impacted

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

Select

OTHER Site

If site was not listed above, please add here

Incident Type

Select the type of incident(s) being reported

Select

Incident- Natural Disaster

Select

Incident- Public Health Emergency

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Incident- Man-made Disaster

Select

Incident- Technological Incident

Select

Incident- Severe Weather Event

Select

Incident- Social/Political Unrest

Select

Incident- OTHER

Incident Status

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

Site Operational Status

Indicate the current operational status of the site impacted

Select

Reason for Status

Select

OTHER Reason for Status

Expected Reopening Date

Indicate the date the site is expected to reopen

Services Impacted

Indicate what services have been impacted by the incident being reported

Staffing Level

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

Priorities

What are your top priorities at this time?

Select

OTHER Priorities

Support Needed

Indicate the type of support that is needed at this time and elaborate in 'Additional Info' below

Select

Disaster Relief Organizations

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.

Request Site Visit

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

Incident Contact

If different from person submitting form

Incident Contact Title

If different from person submitting form

Incident Contact Email

If different from person submitting form

Additional Info

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

Send me a copy of my responses

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