Form 57.803 All Hazards

Form Approved

OMB No. 0920-0666

Exp. Date: 00/00/00

www.cdc.gov/nhsn

Revised 6_17_2024

Critical Infrastructure – Essential Elements of Information Data Form

Instructions for this form are available at: here

Page 1 of 2
Facility Information
Facility ID Number:
Event Date: Month/Year: ___________ /______
Status Indicator – Facility Operational Status
1a.Check the appropriate facility operational status*:
□ normal, routine operational, conventional state: facility NOT impacted
□ contingency state: facility operations partially impacted, or managed on alternate power source □ emergency state: facility operations fully impacted
Note: If facility reports normal / routine / conventional state in place – do not complete this form. However, complete once operational status changes. If either contingency or emergency sate reported proceed to complete this form.
1.Essential Elements of Information (EEIs) – Please complete all fields – do not leave blank.
1b. Is the facility structural status impacted?		Check one: □ Yes □ No
1c. Is the facility power system impacted?		Check one: □ Yes □ No
1d.Is the facility water system impacted?		Check One: □ Yes □ No
1e.Is the facility sewer system impacted?		Check One: □ Yes □ No
2.Essential Elements of Information (EEI) – Structural Damage
2a.Select the option that best represents the integrity of the facility:		Select only One Option: □ No damage: facility sustained no damages □ Affected: facility with minimal damage to the exterior and or contents of the facility □ Minor: encompasses a wide range of damage that does not affect the structural integrity of the facility □ Destroyed: the facility is a total loss, or damaged to such an extent that repair is not feasible
Essential Elements of Information (EEI) – Facility Evacuation Status. Please note the evacuation process applies ONLY to patients
3a.Select the option which best describe the facility evacuation status:		Select only one option □ Planning: preparing to evacuate from the facility within the next 12 hours □ Departure in progress: currently evacuating the facility □ Fully evacuated: facility evacuated all patients □ Not applicable: did not evacuate
Essential Elements of Information (EEI) – Evacuation Status. Please note the evacuation process applies ONLY to patients
3b.Select the option which best represents the evacuation type of the facility:		Select only one option □ Normal operations: facility did not evacuate or shelter-in-place (unaffected) □ Full evacuation: facility evacuated all patients □ Partial evacuation: select patients evacuated to other facilities (note: decompression by discharge is not included in partial evacuation) □ Shelter-in-place: facility did not evacuate and is weathering the storm
Essential Elements of Information (EEI) – Evacuation Start Time and End Time. Please note the evacuation process applies ONLY to patients
3c.*Enter Evacuation Start time *Note: Only complete if your facility evacuated		Enter the time the evacuation started, using format. ___ : ____ hh mm
3d*Enter Evacuation End time *Note: only complete if your facility evacuated and evacuation completed.		Enter the time the evacuation ended, using format: ___ : ____ hh mm
Essential Elements of Information (EEI) – Re-entry Status
3e.Select the option which best represents the re-entry status of the facility:		Select only one option □ Planning: preparing to re-enter the facility □ Re-entry in progress: implementing re-entry process into the facility □ Re-entry complete: all required elements to re-enter the facility completed □ Not applicable: did not evacuate
Essential Elements of Information (EEI) – Generator Power Status, Generator Fuel Status, Generator Fuel Type
4a.Generator Power Status Select the option which best describes the type of power the facility is currently using:		Select Only One option □ Commercial power: sold by utility company □ Generator power: device convert mechanical energy into electrical power □ Mixed commercial and generator power: both commercial and mechanical energy □ No power: facility is without commercial and generator power

Page 2 of 2
Essential Elements of Information (EEI) – Generator, Power Status, Generator Fuel Status, Generator Fuel Type, HVAC Generator Status
4c.Generator Fuel Status Specify how may hours of fuel the generator has for the facility	Select Only One option □ 28 – 48 hours □ 48 – 72 hours □ 72 – 96 hours □ > 96 hours
4c.Generator Fuel Type Select the type of fuel the facility generator needs for operation	Select Only One option □ Diesel □ Gasoline □ Natural gas □ Dual fuel system (both liquid fuel and natural gas) □ Unknown
4d. HVAC Generator Status Is the facility HVAC* system on generator backup power? *Heating, ventilation, and air conditioning (HVAC)	Check One: □ Yes □ No
Essential Elements of Information (EEI) – Water System
5a.Normal Water Supply Select the option which best represents the water supply for your facility?	Check One: □ Usual water supply □ Secondary water supply □ Unknown
5b.Dialysis Reliable Water Supply Do you have a water source to dialyze patients?	Check One: □ Yes □ No □ Unknown
Essential Elements of Information (EEI) – Sewer System
6a.Sewer Status Is the facility sewer system functioning (e.g., are toilets flushing)?	Check One: □ Yes □ No □ Unknown
Essential Elements of Information - Other
7a.Immediate Needs* Does the facility have ANY immediate needs impacting its ability to receive or care for patients to the capacity needed that is not being met by the normal request process? *Note: Please contact your local/state emergency manager or ESF8 contact to complete a resource request.	Check One: □ Yes □ No □ Not Applicable
7b. If yes, to Immediate Needs Describe facility immediate needs (Field cannot contain more than 2000 characters):

Description – Immediate Needs

Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666).