Cdph 5000 A Form – Fill Out and Use This PDF

State of California-Health and Human Services Agency

California Department of Public Health

Temporary Permission for Emergency Program Flexibility

This form is to be used ONLY for program flexibility requests when hospitals temporarily need to comply with licensing requirements by using alternative concepts, methods, procedures, techniques, equipment, or personnel due to an emergency.

Hospitals are required to submit a program flexibility request to the California Department of Public Health (CDPH), Licensing & Certification (L&C) Program through their local district office for written approval. This form is a mechanism to expedite the request and approval process in emergency situations.

Instructions: Complete one form for each request. Fax the completed form to the appropriate district office. For your convenience the list of all District Office addresses and contact information can be found using the following link:

http://www.cdph.ca.gov/certlic/facilities/Pages/LCDistrictOffices.aspx

	Facility Name							Request Date
	License Number							Facility Phone Number
	Facility Address							Facility Fax Number
	City		State		Zip Code			Contact Person Name

Notification of Emergency Tent Use

Emergency tent use

Hospital has obtained written approval from the local fire authority for tent use, and

a. The Governor has declared an emergency, as defined in Government Code (GC) Section 8558, for the hospital’s geographical area and stated that a health care surge exists, or

b. An authorized local official, such as a local health officer or other appropriate designee, has declared a local emergency, as defined in GC Section 8558, for the hospital’s geographical area and stated that a health care surge exists.

Approval Request

Select the Request (Check all at apply):

Tent use (High patient volume)		Space conversion (Other than tent use)		Bed use		Over bedding

Program Flex Request

What regulation are you requesting program flexibility for?

For CDPH Use Only:

CDPH Licensing & Certification Approval:

Permission Granted from: ______________________ to _____________________

Permission Denied: Briefly describe why request was denied in comments / conditions below:

Comments / conditions:

	______________________________________________________________________	_______________________
	L&C District Office Staff Signature	Date

CDPH 5000 A (2/13)

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	State of California-Health and Human Services Agency			California Department of Public Health
	Facility Name		License Number		Request Date

Provide a brief description of your problem and explain why you are requesting the program flexibility. Additionally, please provide a brief description of the alternative concepts, methods, procedures, techniques, equipment or personnel to be used during the emergency situation, and applicable conditions under which this program flexibility will be utilized. Attach supporting additional supporting documentation as needed.

______________________________________________	_____________________________________________
Signature of person requesting the flex	Title
______________________________________________
Printed name

Note: Approval for Space Conversion, Bed Use and Over-Bedding will be time limited and dependent on the facts presented that substantiates the emergency. Initial approval may be given verbally, but a signed written approval must be distributed (faxed) to the hospital and filed in the hospital’s facility folder.

CDPH 5000 A (2/13)

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