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

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* 2. Facility Name

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

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

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

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

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

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

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

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

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

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

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

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

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

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* 29. Have you reported generator-related details to NYCEM or US Army Corps in prior surveys?

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

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* 31. Please share any additional notes or comments:

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