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Healthcare Resource Assessment - EMS
This survey is designed to collect information on disaster-related assets within your agency
1. Agency Name:
2. Jurisdiction(s) Covered (please select all that apply):
3. 24/7 Primary Agency Contact Name:
4. 24/7 Primary Agency Contact E-mail:
5. 24/7 Primary Agency Contact Phone:
6. 24/7 Alternate Agency Contact Name:
7. 24/7 Alternate Agency Contact E-mail:
8. 24/7 Alternate Agency Contact Phone:
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This form was created inside of State.co.us Executive Branch.