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Healthcare Facility Survey
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1.
Completed By (Last Name, First Name)
(Required.)
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2.
Facility Name
(Required.)
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3.
Facility Type
(Required.)
Adult Care Facility
Adult Day Health Care
Ambulatory Surgical Center
Community Mental Health Center
Diagnostic Treatment Center
Dialysis Facility
Federally Qualified Health Center
Home Health Care Agency
Hospice
Hospital
Imaging Center
Nursing Home
Organ Procurement Organization
Outpatient Physical Therapy
Outpatient Rehabilitation Facility
Psychiatric Residential Treatment Facility
Traumatic Brain Injury Facility
Other
If "other," please specify
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4.
Facility Address (Borough)
(Required.)
Brooklyn
Bronx
Manhattan
Queens
Staten Island
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5.
Facility Address (Street)
(Required.)
6.
Facility Address (Suite, Apartment, etc.)
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7.
Facility Address (Zipcode)
(Required.)
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8.
Facility Information
(Required.)
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:
(Required.)
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10.
Facility Administrator Information
(Required.)
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)
(Required.)
Last Name:
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First Name:
Title/Position:
Email Address:
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Cell Phone Number (XXX) XXX-XXXX:
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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.
(Required.)
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)?
(Required.)
Yes
No
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?
(Required.)
Yes
No
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):
(Required.)
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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)
(Required.)
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17.
Please list your transportation assets and/or services, owned or have contracted access to (e.g., car, paratransit):
(Required.)
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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)?
(Required.)
Yes
No
Not Sure
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19.
Does your facility have quick-connects on the electrical panel for generator hook up?
(Required.)
Yes
No
Not sure
If yes, what type?
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20.
Do you have a generator on-site?
(Required.)
Yes
No
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.
21.
Does your facility have a Government Emergency Telecommunications Service (GETS) card?
Yes
No
Not Sure
22.
How many additional beds and/or cots do you have for potential surge during an emergency?
23.
Please include any additional details about beds/cots for potential surge during an emergency, if applicable:
24.
How many additional beds could be stored on site on a temporary basis?
25.
If you had additional beds, how many more patients would you have space to surge?
26.
Please include any additional details about space, if applicable:
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)
28.
Could you purchase more food ahead of a coastal storm if surge is a possibility?
Yes
No
N/A
29.
With your current supply of food, how many days could you feed both staff and patients?
30.
Please share any additional notes or comments:
