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Healthcare Resource Assessment - Ancillary Healthcare
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an emergency.
1. Name of agency:
2. Location of facility/facilities (county) - select all that apply:
La Plata County
San Juan County
Southern Ute Indian Tribe
Ute Mountain Ute Indian Tribe
3. 24/7 primary agency contact - Name:
4. 24/7 primary agency contact - Phone:
5. 24/7 primary agency contact - E-mail:
6. Facility type(s) - select all that apply:
Ambulatory Surgery Center
Long Term Care
Skilled Nursing Center
Federally Qualified Health Center
Continuing Care Retirement Community (CCRC)
7. Total number of beds in your facility - please specify type of beds, if needed:
8. Does your facility provide residential (over night) services?
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