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Have parts of the form filled out ahead of time.

If your practice is an unfortunate victim to some sort of natural disaster — whether it is a simple storm causing power outages or a tornado that has done extensive damage — assessing the situation is going to be your first step to post-disaster recovery. Having a checklist like this one handy to quickly assess the damage, will speed up the process. Use this template as a basis and tailor it to your practice’s specific needs.

Tip: Fill in important information, such as utility service account numbers and data storage location contact information, ahead of time. Then, save a copy of this form somewhere offsite that is likely to be accessible if your practice is not.

Post-Disaster Impact Assessment Form

Practice:__________________________________________    Location Type:_____________________________________

Address:__________________________________________    County:__________________________________________

Contact Person Name:_______________________________    Number__________________________________________

Impact: Practice Open                      Practice Closed

Type of Impact:_________ Increased Patient Surge________ Power Out_____________

Water System Out ________ Foundation Damage_________ Sewage Out_________

Wall Damage__________ Mechanical Damage___________ Flooding_________________ Elevator damage

Severity of Impact: Major         Minor         Some Impact

1. Structure:

    Fully Functional      Partially Functional       Non-Functional

    Roof Leaking  Roof Missing  Windows Out  Non-Intact Walls

2. Power:

    Power On              Power Off            Generator

    Time Left On Fuel Supply____________________________

    HVAC Operational:            Yes         No

3. Water: Normal          Boil Water       No Water

4. Communications: Fully Functional     Partially Functional    Not Functional

5. Supplies: No Shortages          Adequate but Limited    Critical Shortage

6. Operations: Fully Functional           Partially Functional    Not Functional

7. Sanitation Systems: Fully Functional  Partially Functional    Not Functional

8. Radiation/ Oncology: Fully functional   
Partially Functional    Not Functional     N/A

9. Transportation to Offsite Services:

    Available/Functional    Not Available/Non-functional     N/A

10.  Evacuations Status:

    â–¡ Completed

    â–¡ In Process

    â–¡ Planning

    â–¡ Return

    â–¡ Undecided

    Number Evacuated:_________________________________ Destination:_______________________________________

11.  Facility Needs:

    â–¡ Food

    â–¡ Water

    â–¡ Ice

    â–¡ Generator

    â–¡ Generator Fuel

    â–¡ Medical Assistance

    â–¡ Oxygen

    â–¡ Medical Equipment

    â–¡ Non-Medical Equipment

    â–¡ Portable Toilets

    â–¡ Security

    â–¡ Solution

    â–¡ Transportation

    â–¡ Ventilators

    â–¡ Tents

    â–¡ Staff:   ICU    Med/Surg    Pediatrics    Neonatal    Amount needed:_____________________________

    â–¡ Physicians: Type needed_______________________

    â–¡ Other:______________________________________

12.  Power:   Company Name________________________________           Account #_____________________________________

13.  Water:   Company Name_________________________________          Account #_____________________________________

14.  Sewer:   Company Name________________________________           Account #_____________________________________

15.  Offsite Data Storage:   Company Name______________________________    Account #__________________________________