Healthcare Facility Form Crosswalk

Revisions to Form CMS-10752 Submissions of 1135 Waiver Request Inquiry Webform

Issue #	Page #	Section	Action to be performed	Changes to the Application	Reason for the Change
	1	Introduction text	Revised as follows:	Updated important text color from orange to dark green to pass 508-compliant color contrast text, added OMB Control Number and Expiration Date.	508 compliance
	1	All	Revised as follows:	Removed: The term “beneficiary” Replaced with: The terms “patient/resident”	The terms “patient/resident” are more commonly understood than “beneficiary”.
	1	All	Revised as follows:	Added “help text” to form fields and terms that needed explanations to the entire form.	Added help text to aid users in completing the submission.
	1	Section: What would you like to do?	Revised language	Replaced: I want to provide a status update on my beneficiaries and/or healthcare facility With: I want to provide a status on my healthcare facility, patients and or residents	The terms “patient/resident” are more commonly understood than “beneficiary”.
	1	Section 1	Revised as follows:	Added: Emergency Event w/ dropdown selection	This form will be submitted for any emergency, not just a Public Health Emergency (PHE). We added a non-PHE option to accommodate this.
	1	Section 2: Organization Information	Revise as follows:	Changed order: Moved Organization Information section to the top of the section	We moved the section to improve the readability and flow of questions.
	1	Section 2: Organization Information	Revise as follows	Moved: Evacuation Status and Operational Status dropdowns from Emergent Event Information to Organization Information.	We moved the section to improve the readability and flow of questions.
	1	Section 2: Organization Information	Revise as follows:	Removed: Organization Category radio buttons Added: Organization Category dropdowns	We replaced the radio buttons with dropdowns to make the section consistent with the rest of the form.
	1	Section 2: Organization Information	Revise as follows:	Removed: Organization ID Number/CCN text area Added: Organization ID Number/CCN text field	We replaced the text area with a text field to make the section consistent with the rest of the form.
	1	Section 2: Patient/Resident Information	Revise as follows:	Added new section, Patient/Resident Information.	We added this section to ensure that CMS captures all relevant information necessary to aid the health care facility.
	1	Section 2: Patient/Resident Information	Revise as follows To Patient/Resident section from emergent event section	Moved: Number of beds or stations field Moved: Number of patients/residents with injuries Moved: Number of patients/resident fatalities From: Emergent Event Information	We moved the section to improve the readability and flow of questions.
	1	Section 2: Facility census information	Revise as follows: To Patient/Resident section from emergent event section	Moved: Census field Moved: Number of patients/residents evacuated Moved: Number of patients/residents repatriated	We moved the section to improve the readability and flow of questions.
	1	Section 2: Patient/Resident Information	Revise as follows: To Patient/Resident section from emergent event section	Moved: Details of HCF status text area, to this section	We moved the section to improve the readability and flow of questions.
	1	Section 2: Point of Contact	Reorder section	Moved from lower on the form to higher up on the page to under Facility Census Information	We moved the section to improve the readability and flow of questions.
	1	Section 3: Impact to Facility	Revise as follows	Previous title: Emergent Event Information New title: Impact to Facility	We changed the title to more accurately reflect the information being requested.
	1	Section 3: Impact to Facility	Add as follows:	New introduction text: Please complete the following fields to notify us of your current status to facilitate the provision of aid from Federal resources.	Added instructional text to aid users in completing the submission.
	1	Section 3: Impact to Facility	Add as follows:	Add checkbox for: Structural damage w/ subsequent options for damage type	This checkbox was added to give users a mechanism for indicating the kind of structural damage sustained.
	1	Section 3: Impact to Facility	Add as follows:	Add checkbox for: Power loss w/ subsequent options for power loss types, including dropdowns for generator and generator fuel types	This checkbox was added to give users a mechanism for indicating the kind of power loss sustained.
	1	Section 3: Impact to Facility	Add as follows:	Add checkbox for: HVAC loss w/ subsequent options for loss types.	This checkbox was added to give users a mechanism for indicating the kind of HVAC loss sustained.
	1	Section 3: Impact to Facility	Add as follows:	Add checkboxes for: Other impacts to facility	This checkbox was added to give users a mechanism for indicating impacts not represented in the selectable options.
	1	Section 3: Impact to Facility	Add as follows:	Add text area for: Describe the impact	This area was added to give users an area to describe the full impact to the facility.

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