> **HHS Critical Infrastructure Data Request**

**Attention: *Mental Health and Substance Abuse Agencies***

The U.S. Department of Health and Human Services (HHS) has an urgent
need to generate a status report for the victims of Hurricane Katrina.
To facilitate the process for all states involved in relief efforts, we
are immediately making available to you the HHS Critical Infrastructure
Data System for your use. Your current operational status is a priority
as we make efforts to care for the victims and to meet your on-going
needs.

The HHS Critical Infrastructure Data System has been created to capture
information on the following:

-   The current status of facility resources (what you have)

-   Critical resource requirements (what you need)

-   Daily contact diagnosis and symptom information (what you are
    surveying)

You will be entering the following information:

  ----------------------------------- -----------------------------------
  **Update As-Needed**                **Update (24hr Census )**

  Operations Status                   Daily Census

  Critical Resources Needed           Daily Surveillance (of
                                      Diseases/Symptoms)

                                      
  ----------------------------------- -----------------------------------

Daily input into this database will allow HHS and state health officers
to assess information and provide census data as well as ensure the most
effective and high quality care based on real-time data.

[**Training for Databases**.]{.underline}

You may access recorded training on line at
<http://info.EMSystem.com/hhs/mhsatraining> after 5:00 pm, Sunday
September 11, 2005 EDT).

Data may be entered daily by each facility via the World Wide Web at:
[www.EMSystem.com](http://www.EMSystem.com/) .

-   You will need a **USER ID** and **PASSWORD**.

-   Sign up on line at: <http://info.EMSystem.com/hhs/mhsatraining>

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-   Have your authorized staff person contact HHS at
    ***1-866-849-8059*** to get detailed instructions and registration
    information.

[**Facilities without Internet access or Prefer to provide via FAX or
Phone**.]{.underline}

-   Have your authorized staff person fax daily status response forms to
    ***1-866-882-0248*** or verbally provide your update via the HHS
    call center at ***1-866-849-8059***. The forms to be faxed are
    attached.

The database is a password protected, encrypted site. Only authorized
staff of HHS and its contractors working on Hurricane Katrina relief
efforts will have access to these data in addition to your state health
department and Emergency Operations Center.

**[HHS Critical Infrastructure Data Request]{.underline}**

# 

**[FAX FORM Cover Sheet]{.underline}**

**HHS Call Center**: 1-866-849-8059

**HHS Fax**: 1-866-882-0248

**Website**: [www.EMSystem.com]{.underline}

**Date of Collection (24 hr. reporting
period):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Type of Facility (X in Box)**

-   **Mental Health and Substance Abuse Agencies(s)**

**Facility
Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**City \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
State\_\_\_\_\_\_\_\_\_\_\_\_**

**Name/Phone \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
E-Mail\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Pages Faxed, including Cover Sheet:**

**Once all forms are completed, fax to: 1-866-882-0248**

> **Mental Health and Substance Abuse Agencies**

###### 

###### OPERATIONS

+---------------+--------+---------+---------------------------------+
| ## Date       |        |         | **Contact/Phone**               |
+---------------+--------+---------+---------------------------------+
| **Facility    |        |         | **E-mail**                      |
| Name**        |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Address**   |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| *             |        |         |                                 |
| *City/State** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Inpatient   |        |         |                                 |
| Schools Out   |        |         |                                 |
| Patient Group |        |         |                                 |
| Home Day      |        |         |                                 |
| Treatment/Reh |        |         |                                 |
| abilitation** |        |         |                                 |
|               |        |         |                                 |
| **Forensic    |        |         |                                 |
| Mental Health |        |         |                                 |
| and Criminal  |        |         |                                 |
| Justice**     |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| ####### Ope   |        |         |                                 |
| ration Status |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| -   **Fully   |        |         |                                 |
|               |        |         |                                 |
|  Operational/ |        |         |                                 |
|     Normal    |        |         |                                 |
|               |        |         |                                 |
|  Operations** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| -   *         |        |         |                                 |
| *Operational/ |        |         |                                 |
|               |        |         |                                 |
|    Diminished |        |         |                                 |
|               |        |         |                                 |
|    Capacity** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| -   **Closed  |        |         |                                 |
|     but       |        |         |                                 |
|     Expected  |        |         |                                 |
|     to        |        |         |                                 |
|     Re-Open   |        |         |                                 |
|     Estimated |        |         |                                 |
|     Date      |        |         |                                 |
|               |        |         |                                 |
|  Operational\ |        |         |                                 |
| _\_\_\_\_\_\_ |        |         |                                 |
| \_\_\_\_\_\_\ |        |         |                                 |
| _\_\_\_\_\_** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| -             |        |         |                                 |
|  **Closed/Not |        |         |                                 |
|     Expected  |        |         |                                 |
|     to        |        |         |                                 |
|     Re-Open   |        |         |                                 |
|     In Near   |        |         |                                 |
|     Future**  |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **C           |        |         |                                 |
| lient/Patient |        |         |                                 |
| Encounter     |        |         |                                 |
| Data**        |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Average     |        |         |                                 |
| Daily Patient |        |         |                                 |
| Encounter     |        |         |                                 |
| Prior to      |        |         |                                 |
| Event**       |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Number of   |        |         |                                 |
| Patient       |        |         |                                 |
| Encounters in |        |         |                                 |
| Last 24       |        |         |                                 |
| hours**       |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| ####### Crit  |        |         |                                 |
| ical Resource |        |         |                                 |
|  Needs /Staff |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Personnel** | **Pre  | *       | **Request Already Submitted**   |
|               | sent** | *Future |                                 |
|               |        | Need**  |                                 |
+---------------+--------+---------+---------------------------------+
| **P           |        |         |                                 |
| sychiatrist** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Substance   |        |         |                                 |
| Abuse**       |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Mental      |        |         |                                 |
| Health**      |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Case        |        |         |                                 |
| Manger**      |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **A           |        |         |                                 |
| dministrative |        |         |                                 |
| Staff**       |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Total**     |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Critical    |        |         |                                 |
| Resources     |        |         |                                 |
| Nee           |        |         |                                 |
| ds/Supplies** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Resource    | **Pre  | *       | **Request Already Submitted**   |
| Type**        | sent** | *Future |                                 |
|               |        | Need**  |                                 |
+---------------+--------+---------+---------------------------------+
| #             |        |         |                                 |
| ## Child Care |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Security**  |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Janitorial  |        |         |                                 |
| Services**    |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| ### C         |        |         |                                 |
| ommunications |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Internet**  |        |         |                                 |
|               |        |         |                                 |
| *             |        |         |                                 |
| *Connection** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Phar        |        |         |                                 |
| maceuticals** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **First Aid   |        |         |                                 |
| Supplies**    |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Food**      |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Water**     |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Power**     |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Generator** |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Fuel**      |        |         |                                 |
+---------------+--------+---------+---------------------------------+
| **Total**     |        |         |                                 |
+---------------+--------+---------+---------------------------------+

> Go to next page for disease surveillance

##### 

##### 

##### Mental Health and Substance Abuse Agencies

##### 

#####  DAILY SURVEILLANCE REPORT

+------------------------------------+--------------------+------------+
| ## Date                            | **Contact/Phone**  |            |
+------------------------------------+--------------------+------------+
| **Facility Name**                  | **E-mail**         |            |
+------------------------------------+--------------------+------------+
| **City/State**                     |                    |            |
+------------------------------------+--------------------+------------+
| **Symptom Category**               |                    | **\#       |
|                                    |                    | Patients   |
|                                    |                    | with       |
|                                    |                    | C          |
|                                    |                    | ondition** |
+------------------------------------+--------------------+------------+
| # Me                               |                    |            |
| ntal Health/Psychological Problems |                    |            |
+------------------------------------+--------------------+------------+
| Anxiety/Depression/Post Traumatic  |                    |            |
| Stress Disorder                    |                    |            |
+------------------------------------+--------------------+------------+
| Substance abuse/withdrawal         |                    |            |
+------------------------------------+--------------------+------------+
| Disorientation/Confusion           |                    |            |
+------------------------------------+--------------------+------------+
| Acute Psychosis                    |                    |            |
+------------------------------------+--------------------+------------+
| Violent Behavior                   |                    |            |
+------------------------------------+--------------------+------------+
| Lack of Medication                 |                    |            |
+------------------------------------+--------------------+------------+
| Other Condition (Please Specify)   |                    |            |
+------------------------------------+--------------------+------------+
| # Injury/Chronic Disease/Other     |                    |            |
+------------------------------------+--------------------+------------+
| ### Injury                         |                    |            |
+------------------------------------+--------------------+------------+
| -   Self-inflicted injury --       |                    |            |
|     Intentional (violence)         |                    |            |
+------------------------------------+--------------------+------------+
| -   Assault-related injury-        |                    |            |
|     Intentional (violence)         |                    |            |
+------------------------------------+--------------------+------------+
| -   Unintentional injury           |                    |            |
|     (accidents)                    |                    |            |
+------------------------------------+--------------------+------------+
| -   Heat related injury (not       |                    |            |
|     dehydration)                   |                    |            |
+------------------------------------+--------------------+------------+
| Other (Please Specify)             |                    |            |
+------------------------------------+--------------------+------------+