Interruption in Service Form

Instructions: For all facility closures or interruptions in service, please complete this form. Reach out to esrddata@comagine.org if you have any issues completing.
NW15/18 State

NW15/18 State Arizona (AZ) Colorado (CO) New Mexico (NM) Nevada (NV) Utah (UT) Wyoming (WY) Southern California
Facility (NW15-AZ)
Facility (NW15 CO)
Facility (NW15 NM)
Facility (NW15 NV)
Facility (NW15 UT)
Facility (NW15 WY)
Facility (NW18 Southern California)
State-County (NW15)
State-County (NW18)
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
Is closure/interruption permanent or temporary?

Is closure/interruption permanent or temporary? Permanent Temporary
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
Select what was closed:

Select what was closed: Entire Facility Shift(s) Station(s)
# of shifts closed
# of stations closed
Closure is due to

Closure is due to Facility issues (water system, HVAC, leaks) Evacuation orders Staffing
Select reason for staffing shortage (select all that apply)

Select reason for staffing shortage (select all that apply) Staff illness/emergency Other Other
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.
Were patients contacted about the closure/interruption?

Were patients contacted about the closure/interruption? Yes No
How were patients contacted about the closure/interruption?
Did any patients experience shortened treatments because of the closure/interruption?

Did any patients experience shortened treatments because of the closure/interruption? Yes No
Were Patients Rescheduled?

Were Patients Rescheduled? Yes No
How many patients were rescheduled?
Have patients been relocated to another unit?

Have patients been relocated to another unit? Yes No
Where have the patients been relocated to? Please list all units along with the number of patients relocated to each location
Do you need help with transportation for this event?

Do you need help with transportation for this event? Yes No
Did any patients not receive treatment?

Did any patients not receive treatment? Yes No
How many patients did not receive treatment?
Were the patients that did not receive treatment evaluated for fluid/medical status and informed of when to seek emergency care?

Were the patients that did not receive treatment evaluated for fluid/medical status and informed of when to seek emergency care? Yes No
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

Network 15/18 Facility Closure/Interruption in Service Form

Network 15/18 Facility Closure/Interruption in Service Form

Instructions: For all facility closures or interruptions in service, please complete this form. Reach out to esrddata@comagine.org if you have any issues completing.

REMINDER: No PHI/PII in any fields.