Healthcare Facility Readiness Assessment Form
Use this form to assess whether a healthcare facility is ready to operate safely and effectively.
Facility Identification
Facility Name
*
Facility Type
*
Hospital
Clinic
Urgent Care
Ambulatory Surgery Center
Long-Term Care Facility
Other
Location / City
*
Primary Contact Name and Role / Title
*
Readiness Assessment
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Readiness Level
*
Not ready
Partially ready
Mostly ready
Fully ready
Readiness Scoring Grid
*
Rows
Not in place
Developing
Adequate
Strong
Staffing
1
2
3
4
Supplies
5
6
7
8
Equipment
9
10
11
12
Infection control
13
14
15
16
Emergency preparedness
17
18
19
20
Documentation
21
22
23
24
Gaps and Actions
Top readiness gap or deficiency 1
*
Top readiness gap or deficiency 2
*
Top readiness gap or deficiency 3
*
Immediate actions needed before launch or inspection
*
Target completion date for corrective actions
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
Should be Empty: