Facility Closure/Interruption in Service Form

Instructions: For all facility closures or interruptions in service, please complete this form.
CCN – Network 18 and Facility Name *

Select your appropriate Network, CCN and Facility Name.
County *
Today's Date Today's Date * / MM / DD YYYY
Facility Contact Facility Contact * First Last
Facility Contact Phone # Facility Contact Phone # * - ### - ### ####
Facility Contact Email *
Date the Closure/Interruption Began Date the Closure/Interruption Began / MM / DD YYYY
Date Services were or will be Restored (estimate for future dates is fine) Date Services were or will be Restored (estimate for future dates is fine) / MM / DD YYYY
Number of hours or days the Closure/Interruption lasted or will last
Current Condition of your facility *

Current Condition of your facility Normal Operations or Situation Resolved- No Assistance Required Situation Under Control- No Assistance Required Modified or Limited Services- No Assistance Required Modified or Limited Services- Network Assistance Required No Services Available- No Assistance Required No Services Available- Network Assistance Required
Please describe the nature of the closure/interruption in service. *
***

WARNING: DO NOT ENTER PHI/PII ON THIS FORM.
No PHI/PII in the fields below. Examples of PHI include patient name or initials, birthdate, SSN, etc.
Were patients contacted about the closure/interruption?

Were patients contacted about the closure/interruption? Yes No
If you answered "Yes" above, how were patients contacted?
Were Patients Rescheduled? *

Were Patients Rescheduled? Yes No
If you Answered "Yes" above, how many patients were rescheduled?
Have Patients been relocated to another unit? *

Have Patients been relocated to another unit? Yes No
If you answered "Yes" above, where have they been relocated to? Please list all units along with the number of patients relocated to each location
Did any patients not receive treatment?

Did any patients not receive treatment? Yes No
If you answered "Yes" above, how many?
REMINDER: No PHI/PII in any fields.

Please review your data and check this box to verify that no PHI/PII is included
Check here to verify *

Check here to verify I agree that no PHI/PII is included in this form
The process for submitting an Interruption of Service/Closure using this form was:

The process for submitting an Interruption of Service/Closure using this form was: 5- Excellent/Convenient 4- Very Good 3- Neutral 2- Not Good 1- Poor/Inconvenient

Facility Closure/Interruption in Service Form

Facility Closure/Interruption in Service Form

Instructions: For all facility closures or interruptions in service, please complete this form.

***

REMINDER: No PHI/PII in any fields.