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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:
2. Name of Facility:
3. Location of facilities (check all that apply):
4. 24/7 primary organization contact -
5. 24/7 primary organization contact - Phone:
6. 24/7 primary organization contact - E-mail:
7. 24/7 alternate organization contact - Name:
8. 24/7 alternate organization contact - Phone
9. 24/7 alternate organization contact - E-mail:
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This form was created inside of State.co.us Executive Branch.