Healthcare Facility Emergency Assessment Form

Healthcare Facility Emergency Assessment Form
Please complete this form to assess and report your facility’s status and needs during an emergency situation.
Facility Name
Facility Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person Name
First NameLast Name
Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person Email
example@example.com
Date and Time of Assessment
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Type of Emergency
Other
Current Facility Operational Status
Assessment of Critical Resources
Rows Available Limited Not Available
Medical Staff
Support Staff
Medical Supplies
Medications
Beds
Oxygen Supply
Power Supply
Water Supply
How would you rate your facility’s overall emergency preparedness?

1
2
3
4
5
1 is Not prepared, 5 is Fully prepared
Please describe any urgent needs or requests for assistance (e.g., supplies, staff, services)
Additional Comments or Information
Should be Empty:

Select theme: