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Healthcare Resource Assessment - Behavioral Health
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an event.
1. Name and Phone of Person Filling Out Survey: *
Your answer
2. Name of Facility: *
Your answer
3. Location of facilities (check all that apply): *
Required
4. 24/7 primary organization contact - *
Your answer
5. 24/7 primary organization contact - Phone: *
Your answer
6. 24/7 primary organization contact - E-mail: *
Your answer
7. 24/7 alternate organization contact - Name:
Your answer
8. 24/7 alternate organization contact - Phone
Your answer
9. 24/7 alternate organization contact - E-mail:
Your answer
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