Request edit access
Healthcare Resource Assessment: Public Health
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an event.
1. Name of Public Health Department:
2. Jurisdiction(s) covered (select all that apply):
Kit Carson County
3. 24/7 contact for your agency - Name (can enter name of 24/7 phone line, if applicable):
4. 24/7 contact for your agency - Phone:
5. 24/7 contact for your agency - E-mail:
6. 24/7 alternate contact for your agency - Name:
7. 24/7 alternate contact for your agency - Phone:
8. 24/7 alternate contact for your agency - E-mail:
Never submit passwords through Google Forms.
This form was created inside of State.co.us Executive Branch.