Exit this survey KCER Ready! 1. Please complete the questions below to assess your facility's disaster readiness. Question Title * 1. Please select your type of organization. You may select more than one. Dialysis Transplant Hospital Other healthcare provider Patient Organization (NKF, AAKP, etc) Healthcare Provider Organization (ANNA, ASN, etc) ESRD Network Other Government Affiliation (CMS, CDC, etc) Other Question Title * 2. In the past year, has your facility/organization communicated directly with your local emergency management agency? Yes No Question Title * 3. Do you know about your local government’s emergency or disaster plan for your community? Yes No Question Title * 4. Do you know how to find the emergency broadcasting channel on the radio or television? Yes No Question Title * 5. In the last year, has your facility/organization joined or participated with a local Healthcare Coalition? Yes No Question Title * 6. In the last year, has your facility’s/organization’s staff complied with the CMS Emergency Rule training exercise requirements? Yes No Question Title * 7. In the past six months, has your facility/organization provided education to patients on disaster preparedness? Yes No Question Title * 8. In the past six months, has your facility/organization provided education to staff on disaster preparedness? Yes No Question Title * 9. In the past six months, has your facility/organization reviewed and updated the disaster plans? Yes No Question Title * 10. In the last year, has your organization made a specific plan for how you and your staff would communicate with each other and with patients during an emergency situation, including updating contact numbers and addresses? Yes No Question Title * 11. In the last year, has your facility/organization encouraged patients and staff to prepare a Disaster Supply Kit with emergency supplies like water, food and medicine that is kept in a designated place at home? Yes No Question Title * 12. Optional Contact Information Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Country: Email Address: Phone Number: Question Title * 13. Optional Contact Information Name: Company: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Country: Email Address: Phone Number: Done
