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COAD-OC Status Report Form
This form is intended to help your organization report on services provided, seek help in meeting additional needs, and coordinate activities with other agencies for more effective and efficient delivery of services. Submit this form by clicking the "submit" button below or if unable to submit online, please email the form to the COAD-OC Information Sector Leader, whose contact information is listed below.
COAD Information Sector Leader
Name: Amy Arambulo
Email: Disaster@211oc.org
Phone: 714-589-2350
Fax: 714-258-7852
Reporting Period Start Date
MM
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DD
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YYYY
Reporting Period Start Time
Time
:
Reporting Period End Date
MM
/
DD
/
YYYY
Reporting Period End Time
Time
:
Organization
Organization - Name
Your answer
Organization - Street Address
Your answer
Organization - City/Zip
Your answer
Point of Contact
Point of Contact - Name
Your answer
Point of Contact - Email
Your answer
Point of Contact - Mobile Phone
Your answer
Point of Contact - Office Phone
Your answer
Point of Contact - Fax
Your answer
Point of Contact - Ham Radio Call Sign
Your answer
Point of Contact - Accept text messages to your mobile?
Other
Your answer
Volunteers
Volunteers - # Mobilized for this event
(For this reporting period)
Your answer
Volunteers - # Volunteer hours
(For this reporting period)
Your answer
Operational Status
(For this reporting period)
Services your agency is providing
Service Codes
Service Location 1 (Address)
Indicate which service codes are offered at this location (INR 555 Fake St. Santa Ana, CA 92701)
Your answer
Service Location 2 (Address)
Indicate which service codes are offered at this location (INR 555 Fake St. Santa Ana, CA 92701)
Your answer
Service Location 3 (Address)
Comma separate any additional locations in this field
Your answer
# Clients Served
Your answer
Resource shortfall or other operating problems:
Your answer
Unmet needs/problems (including access to functional needs) you have observed in the community:
Your answer
Resources your agency can share:
Your answer
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