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Incident and Impact Alert

Incident and Impact Alert Form

Incident and Impact Alert Form

As part of our role as a Primary Care Association (PCA), Community Care serves as a key liaison with the Health Resources and Services Administration (HRSA) to ensure timely communication and coordination during severe events that significantly impact health center operations.

One of our core responsibilities is to monitor and inform HRSA when a health center experiences an incident that results in major disruption in operations. While we actively track news and social media, especially during severe weather seasons, we rely on health centers to report incidents directly to us.

To streamline this process, we’ve developed a formal Incident and Impact Notification Form. This form helps us assess the situation, initiate internal tracking, and determine the appropriate next steps, including communication with HRSA and other partners.  
We encourage Community Care Member Clinics to review their Memoranda of Agreement (MOAs) with us to ensure they are current and reflect accurate contact and procedural information.

When to Fill Out This Form

Please complete this form as soon as possible when your health center experiences an event that significantly disrupts operations. Below are examples of situations where submitting the form is appropriate, along with the types of impacts we need to be aware of:

  • Natural Disasters 
    Example: A tornado damages the clinic roof, forcing the closure of the site for repairs; flooding prevents staff and patients from safely accessing the facility; a wildfire evacuation order requires temporary relocation of services 
  • Utility Failures 
    Example: A prolonged power outage disables refrigeration for vaccines and medications; water services disruption leads to closure of patient care areas; HVAC failure during extreme temperatures makes the facility unsafe for staff and patients.
  • Cybersecurity Incidents 
    Example: A ransomware attack locks access to electronic health records, halting patient scheduling and documentation; a data breach requires immediate notification and mitigation steps.
  • Facility Closures or Evacuations 
    Example: Structural damage from a vehicle collision or fire renders the building unsafe; a gas leak forces immediate evacuation and temporary service suspension.
  • Staffing Shortages 
    Example: A communicable disease or viral outbreak surge results in multiple staff being out sick, requiring reduced hours or temporary site closure.

If you are unsure whether an event qualifies, we encourage you to submit the form or reach out to us for further guidance. It’s always better to report early so we can assess and support appropriately.

Reporting Process and Points of Contact

  • The Chief Strategy Officer (CSO) at Community Care will serve as the Primary Point of Contact (POC) for all incidents and impact alerts.
  • If another Community Care staff member receives the initial report, they are responsible for notifying the CSO immediately.

We understand that many of our member clinics have established relationships with various Community Care team members. Please know that while you are welcome to reach out to them, you may be redirected to ensure we follow our established protocol.

Incident & Impact Alert Form
Community Care Network of Kansas
700 SW Jackson Street,
Suite 600
Topeka, KS 66603
785-233-8483

STATEMENT OF DISCLOSURE BY COMMUNITY CARE: This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award with 0 percent financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.