Name *

Health Center *

City/Town *

Email *

Phone *

REGION OF SITE - If you are unsure which region your site is located in, please visit: https://www.mthcc.org/. (If reporting for multiple sites, please select all applicable) *

• Western
• Central
• Southern
• Eastern

What county is this site located in? *

Event Type *

• Flood
• Internet Outage
• Cyber Attack
• Wind Event
• Power Outage
• EMR Outage
• Fire
• Snow/ICE
• Other:

Please describe event if other was selected

(Please provide a concise summary)

Brief Description of the Event *

(Please provide a concise summary)

Operational Status *

• Uncertain at this time
• Fully operational
• Open with reduced hours/services
• Virtual Visits only
• Closed
• Other

If closed or reduced hours, please describe the expected duration and plan for returning to normal operations:

Primary reason for site closure (if applicable):

• Air quality
• Compromised Roadways
• Electronic Medical System Down
• Flooding
• Fire
• It/Telecommunication Down
• Lockdown/shelter in place
• Power Outage
• Property Damage
• Snow/Ice
• Staffing
• Supply Shortage
• Other:

Please describe if other was selected

(Please provide a concise summary)

Facility Damage Assessment - Has your health center sustained any damage (check all that are 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 back up power
• Power outage – on generator or back up power
• Vaccines/pharmaceuticals evacuated
• Communication outage – telephones/call center
• Communication outage – internet
• IT failure- EMR/practice management/financial systems
• Other utility failure – water, sewer, gas
• Other:

Please describe if other was selected

(Please provide a concise summary)

Notification of Operational Changes - Have you communicated these operational change to any of the following (check all that are applicable)?

• Montana Department of Public Health
• Local Board of Health/Local Health Officer
• Regional Health Care Coalition (https://www.mthcc.org/)
• Affiliated Hospitals
• Vendors
• Contracted Services (such as pharmacies)
• HRSA point of contact
• Local Emergency Management Disaster
• Patients
• Other (please specify)

Please describe if other was selected

(Please provide a concise summary)

Assistance Needed - Do you require assistance from the Montana Primary Care Association or other agencies? (If yes, we will contact you directly.) *

• Yes
• No

Top Priorities at This Time (Select all that apply.)

• Safe access to facility
• Rescheduling of patients
• Safety of staff and patients onsite
• Returning to normal operations
• Reduction of potential losses (facility, pharmaceuticals/vaccines, revenue)
• Other (please specify):

Please describe if other was selected

(Please provide a concise summary)

visit: closure regarding

Additional Information - Is there any other information you would like to share regarding this event?

Submit