Dialysis Facility Name: _____________________________________________________ □ □ This Facility is a: Critical Facility Hub ________________________________ Facility Address: Phone ( ) _____________ Fax ( ) Facility _____________ Alternate Emergency Numbers: Administrator Name/Contact Number: Corporate Contact Name/Number: Medical Director Name/Contact Number: Name of Power Company: Number: □Y □N □Y □N Permanent Generator? If NO, is Transfer Switch Installed/Available? Water Storage? Water Hookup? Type of Fuel: Gallons: □Y □N □Y □N _______________ __________________ Number of Isolation Stations: Number of Dialysis Stations: __________ _____________________________ Any Special Disaster Protections: ___________________________ Total Patients Served: _______________ __________________________ ___________________________ __________________________ Comments/Special Instructions:
Dialysis Facility Name: _____________________________________________________ This Facility is a: □ Critical Facility □ Hub Facility Address: Facility Phone ( ) _____________ Fax ( ) _____________ Alternate Emergency Numbers: Administrator Name/Contact Number: Corporate Contact Name/Number: Medical Director Name/Contact Number: Name of Power Company: Number: Permanent Generator? □Y □N If NO, is Transfer Switch Installed/Available? □Y □N Type of Fuel: _______________ Water Storage? □Y □N Gallons: __________________ Water Hookup? □Y □N Number of Dialysis Stations: __________ Number of Isolation Stations: _____________________________ Total Patients Served: _______________ Any Special Disaster Protections: ___________________________ __________________________ ___________________________ __________________________ Comments/Special Instructions: ________________________________
cms_disasterprep-supplementalappendix-of-customizable-forms_508.docx