NW5 Emergency Event
Select your state/Territory/District:
Select your facility
Facility Contact First Name
Facility Contact Last Name
Facility Contact Email
WARNING: DO NOT ENTER PHI / PII ON THIS FORM.
No PHI / PII in the following fields.
Examples of PHI include patient name or initials, birthdate, SSN, etc.
Next Step: Incident Info
Incident Start Date:
Incident Time (if applicable)
Facility operational status
Briefly describe event causing change to facility operations status
When do you expect normal operations to resume?
Next Step: Facility Patient Census
Facility Patient Census
# of in-center patients
# of PD patients
# of home hemo patients
# of isolation patients
# of patients unaccounted for?
Patients have been:
What facilities have your patients been re-routed to?:
If patients rescheduled to alternate time/date provide new schedule:
Generator availability at facility:
Is facility currently using generator to function?
Is the facility having trouble obtaining diesel to refuel generator?
Does facility have an in-center back up supply of water (eg. cistern, storage tank, tanker truck)
Is facility currently using cistern to function?
Is the facility having trouble obtaining water to continue treatments?
What can the Network help your facility with at this time?
Submit this form again if:
a) Your facility does not resume services in the predicted/identified time frame
b) The status of your facility changes
c) Your facility resumes normal operations
d) A new emergency/event or need for assistance is identified
e) One or more of your patients is still unaccounted for
Next Step: Verify and Submit
Verify you are not a robot and submit your data using the Submit button
at bottom of the form