NW5 Emergency Event
Select your state/Territory/District:
Select your facility
Facility Contact First Name
Facility Contact Last Name
Facility Contact Phone
Facility Contact Phone Ext
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?
Do you provide treatment to patients who reside in a nursing home or long term care facility?
If yes, How many of your patients reside in a nursing home or long term care facility?
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?
How are you getting your water to provide dialysis treatments (select all that apply):
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