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If the information you enter here changes, you can re-enter this survey and update your information.

Should you have any questions or concerns, please do not hesitate to contact League staff (twright@massleague.org, jbroderick@massleague.org or the emergency duty officer emergency@massleague.org). Thank you.

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* 1. Your info:

Name:

Health Center:

City/Town:

Email Address:

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* 2. Which region is this site in? For those with multiple sites, please feel free to check all regions you are reporting on.
(Unsure what region you are in, visit: https://matracking.ehs.state.ma.us/hmcc_regions/hmcc_regions.html)

Region 1 - Western MA

Region 2 - Central MA

Region 3 - Northeastern MA

Region 4AB - Greater Boston/Metro Region

Region 4C - Boston

Region 5 - Southeastern MA

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* 3. Based on the forecast for the pending event, will your health center be operational for the next few days (please check starting with whatever day tomorrow is, e.g. if today is Wednesday, report tomorrow's operational status by checking Thursday, and so on. You may check more than one if applicable):

	Mon	Tues	Wed	Thurs	Fri	Sat	Sun
Uncertain at this time	Uncertain at this time Mon	Uncertain at this time Tues	Uncertain at this time Wed	Uncertain at this time Thurs	Uncertain at this time Fri	Uncertain at this time Sat	Uncertain at this time Sun
FULLY OPERATIONAL all day	FULLY OPERATIONAL all day Mon	FULLY OPERATIONAL all day Tues	FULLY OPERATIONAL all day Wed	FULLY OPERATIONAL all day Thurs	FULLY OPERATIONAL all day Fri	FULLY OPERATIONAL all day Sat	FULLY OPERATIONAL all day Sun
MODIFIED SERVICES / TELEHEALTH only, switching to remote operations	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Mon	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Tues	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Wed	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Thurs	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Fri	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Sat	MODIFIED SERVICES / TELEHEALTH only, switching to remote operations Sun
REDUCED SERVICES / STAFFING for urgent care needs only	REDUCED SERVICES / STAFFING for urgent care needs only Mon	REDUCED SERVICES / STAFFING for urgent care needs only Tues	REDUCED SERVICES / STAFFING for urgent care needs only Wed	REDUCED SERVICES / STAFFING for urgent care needs only Thurs	REDUCED SERVICES / STAFFING for urgent care needs only Fri	REDUCED SERVICES / STAFFING for urgent care needs only Sat	REDUCED SERVICES / STAFFING for urgent care needs only Sun
DELAYED OPENING / Reduced hours of operations	DELAYED OPENING / Reduced hours of operations Mon	DELAYED OPENING / Reduced hours of operations Tues	DELAYED OPENING / Reduced hours of operations Wed	DELAYED OPENING / Reduced hours of operations Thurs	DELAYED OPENING / Reduced hours of operations Fri	DELAYED OPENING / Reduced hours of operations Sat	DELAYED OPENING / Reduced hours of operations Sun
CLOSING EARLY / Reduced hours of operations	CLOSING EARLY / Reduced hours of operations Mon	CLOSING EARLY / Reduced hours of operations Tues	CLOSING EARLY / Reduced hours of operations Wed	CLOSING EARLY / Reduced hours of operations Thurs	CLOSING EARLY / Reduced hours of operations Fri	CLOSING EARLY / Reduced hours of operations Sat	CLOSING EARLY / Reduced hours of operations Sun
CLOSED due to event	CLOSED due to event Mon	CLOSED due to event Tues	CLOSED due to event Wed	CLOSED due to event Thurs	CLOSED due to event Fri	CLOSED due to event Sat	CLOSED due to event Sun
CLOSED - as per normal schedule, not event related	CLOSED - as per normal schedule, not event related Mon	CLOSED - as per normal schedule, not event related Tues	CLOSED - as per normal schedule, not event related Wed	CLOSED - as per normal schedule, not event related Thurs	CLOSED - as per normal schedule, not event related Fri	CLOSED - as per normal schedule, not event related Sat	CLOSED - as per normal schedule, not event related Sun

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* 4. Has your health center sustained any damage? (Skip if not applicable)

No Damage

No Damage, but cannot occupy the building as per safety officials

Water damage - burst pipes / flooding

Wind damage

Structural damage from downed limbs and/or debris

Roof damage / collapse

Power outage - no generator or backup power

Power outage - on generator power

Vaccines / pharmaceuticals evacuated

Vaccine / pharmaceutical losses

Communication outage - telephones / call center

Communication outage - internet

IT Failure - EMR / Practice Management / Financial Systems

Other (please specify)

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* 5. Have you communicated any changes in operations to anyone else? (Skip if not applicable.)
Please note that in order to reduce your reporting burden, the League will use the information collected in this survey to inform regional Health & Medical Coordinating Coalitions (HMCCs) and MDPH Office of Preparedness and Emergency Management (OPEM) of your operational status, as appropriate.

Massachusetts Department of Public Health (MDPH)

Local Board of Health / Local Health Officer

Regional Health & Medical Coordinating Coalition (HMCC)

Affiliated Hospitals

Vendors

Contracted Services (such as pharmacies, etc.)

HRSA Project Officer

Local Emergency Management Director

Other (please specify):

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* 6. Do you need any assistance, from the League or other agencies? If yes, we will contact you directly.

Yes

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* 7. What are your top priorities at this time?

Safe access to facility

Rescheduling of patients (from in-clinic to telehealth)

Rescheduling of patients (in-clinic appointments only)

Safety of staff and patients onsite

Returning to normal operations

Reduction of potential losses (facility, pharmaceuticals / vaccines, revenue, etc.)

Other (please specify)

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* 8. As a precaution, please provide us with your health center's emergency contact information (if different from above):

Name:

Email Address:

Phone Number:

EP - Operational Status Reporting - 2022-present

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* 1. Your info:

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* 2. Which region is this site in? For those with multiple sites, please feel free to check all regions you are reporting on.
(Unsure what region you are in, visit: https://matracking.ehs.state.ma.us/hmcc_regions/hmcc_regions.html)

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* 4. Has your health center sustained any damage? (Skip if not applicable)

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* 6. Do you need any assistance, from the League or other agencies? If yes, we will contact you directly.

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* 7. What are your top priorities at this time?

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* 8. As a precaution, please provide us with your health center's emergency contact information (if different from above):

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* 9. Please share any other information that you feel is important for us to know. Thank you.

Question Title

* 1. Your info:

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* 2. Which region is this site in? For those with multiple sites, please feel free to check all regions you are reporting on. (Unsure what region you are in, visit: https://matracking.ehs.state.ma.us/hmcc_regions/hmcc_regions.html)

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* 4. Has your health center sustained any damage? (Skip if not applicable)

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* 6. Do you need any assistance, from the League or other agencies? If yes, we will contact you directly.

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* 7. What are your top priorities at this time?

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* 8. As a precaution, please provide us with your health center's emergency contact information (if different from above):

Question Title

* 9. Please share any other information that you feel is important for us to know. Thank you.

* 2. Which region is this site in? For those with multiple sites, please feel free to check all regions you are reporting on.
(Unsure what region you are in, visit: https://matracking.ehs.state.ma.us/hmcc_regions/hmcc_regions.html)