Healthcare Facility Survey

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* 1. Completed By (Last Name, First Name)

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* 2. Facility Name

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* 3. Facility Type

If "other," please specify

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* 4. Facility Address (Borough)

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* 5. Facility Address (Street)

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* 6. Facility Address (Suite, Apartment, etc.)

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* 7. Facility Address (Zipcode)

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* 8. Facility Information

Facility Owner/Operator (Last Name):

Facility Owner/Operator (First name):

Operating Certificate Number:

Total Number of Certified Beds:

Business Phone Number (XXX) XXX-XXXX:

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* 9. NYS-Issued Facility ID:

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* 10. Facility Administrator Information

Last Name:

First name:

E-mail Address:

Cell Phone Number (XXX) XXX-XXXX:

Business Phone Number (XXX) XXX-XXXX:

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* 11. 24/7 Contact Information (Other Than Administrator)

Last Name: *

First Name:

Title/Position:

Email Address: *

Cell Phone Number (XXX) XXX-XXXX: *

Business Phone Number (XXX) XXX-XXXX: *

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* 12. Which of the following programs does your facility participate in? Check all that apply.

Advance Warning System (AWS)

Partners in Preparedness

Notify NYC

New York City- Health Alert Network (HAN)

Not Applicable

If "Not Applicable", please explain why:

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* 13. Does your facility have an Emergency Plan and/or Continuity of Operations Plan (COOP)?

Yes

Not Sure

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* 14. Is your facility part of a larger health care system or affiliated with an operator who has other like facilities?

Yes

Not sure

If "Yes", please identify the system/network/organization:

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* 15. Please indicate the specific population(s) served by your facility (e.g., dementia care, mental health, veterans):

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* 16. What is the average percentage of electrically dependent patients in your facility (e.g., ventilator or telemetry patients)? (Enter a whole number, do not include the "%" sign)

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* 17. Please list your transportation assets and/or services, owned or have contracted access to (e.g., car, paratransit):

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* 18. Have you identified an appropriate location to place generators in case of emergency, within close proximity to electric room or panel (e.g., courtyard, parking lot)?

Yes

Not Sure

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* 19. Does your facility have quick-connects on the electrical panel for generator hook up?

Yes

Not sure

If yes, what type?

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* 20. Do you have a generator on-site?

Yes

If yes, please list any applicable details (size in kW, manual or automatic configuration, fuel type, voltage, number of hours or days it can be run):

The following questions may be not be applicable to all healthcare facilities, please skip as necessary.

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* 21. Does your facility have a Government Emergency Telecommunications Service (GETS) card?

Yes

Not Sure

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* 22. How many additional beds and/or cots do you have for potential surge during an emergency?

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* 23. Please include any additional details about beds/cots for potential surge during an emergency, if applicable:

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* 24. How many additional beds could be stored on site on a temporary basis?

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* 25. If you had additional beds, how many more patients would you have space to surge?

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* 26. Please include any additional details about space, if applicable:

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* 27. Please select all the fields in which you have adequate commodities and services to support bed surge:

Linens

Medication

Food

N/A

Other (please specify)

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* 28. Could you purchase more food ahead of a coastal storm if surge is a possibility?

Yes

N/A

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* 1. Completed By (Last Name, First Name)

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* 2. Facility Name

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* 3. Facility Type

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* 4. Facility Address (Borough)

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* 5. Facility Address (Street)

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* 6. Facility Address (Suite, Apartment, etc.)

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* 7. Facility Address (Zipcode)

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* 8. Facility Information

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* 9. NYS-Issued Facility ID:

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* 10. Facility Administrator Information

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* 11. 24/7 Contact Information (Other Than Administrator)

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* 12. Which of the following programs does your facility participate in? Check all that apply.

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* 13. Does your facility have an Emergency Plan and/or Continuity of Operations Plan (COOP)?

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* 14. Is your facility part of a larger health care system or affiliated with an operator who has other like facilities?

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* 15. Please indicate the specific population(s) served by your facility (e.g., dementia care, mental health, veterans):

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* 16. What is the average percentage of electrically dependent patients in your facility (e.g., ventilator or telemetry patients)? (Enter a whole number, do not include the "%" sign)

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* 17. Please list your transportation assets and/or services, owned or have contracted access to (e.g., car, paratransit):

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* 18. Have you identified an appropriate location to place generators in case of emergency, within close proximity to electric room or panel (e.g., courtyard, parking lot)?

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* 19. Does your facility have quick-connects on the electrical panel for generator hook up?

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* 20. Do you have a generator on-site?

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* 21. Does your facility have a Government Emergency Telecommunications Service (GETS) card?

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* 22. How many additional beds and/or cots do you have for potential surge during an emergency?

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* 23. Please include any additional details about beds/cots for potential surge during an emergency, if applicable:

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* 24. How many additional beds could be stored on site on a temporary basis?

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* 25. If you had additional beds, how many more patients would you have space to surge?

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* 26. Please include any additional details about space, if applicable:

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* 27. Please select all the fields in which you have adequate commodities and services to support bed surge:

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* 28. Could you purchase more food ahead of a coastal storm if surge is a possibility?

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* 29. With your current supply of food, how many days could you feed both staff and patients?

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* 30. Please share any additional notes or comments: