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Alameda County Medical Health Situational Status Report Form (COVID-19)
Please fill out this form to provide situational awareness of what is currently happening within your facility.
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* Indicates required question
Facility Name
*
Your answer
Facility Address
*
Your answer
Originator Name
*
Your answer
Title
*
Your answer
Department
*
Your answer
Phone #
*
Your answer
Email Address
*
Your answer
Facility Type
*
Choose
Hospital
Clinic
Long Term Care Facility
Skilled Nursing Facility
Dialysis Center
Other
Is your EOC/HCC activated?
*
Not Activated
Virtually Activated
Partially Activated
Fully Activated
EOC/HCC Phone #
*
Your answer
EOC/HCC Email (if applicable)
Your answer
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