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 of person submitting form

Title of person submitting form

Email of person submitting form

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

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If health center was not listed above, please add here

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

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If site was not listed above, please add here

Select the type of incident(s) being reported

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

Indicate the current operational status of the site impacted

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Indicate the date the site is expected to reopen

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?

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

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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 CPCA 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 CPCA to be aware of