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Healthcare Resource Assessment - EMS
This survey is designed to collect information on disaster-related assets within your agency
Email address *
1. Agency Name: *
Your answer
2. Jurisdiction(s) Covered (please select all that apply): *
Required
3. 24/7 Primary Agency Contact Name: *
Your answer
4. 24/7 Primary Agency Contact E-mail: *
Your answer
5. 24/7 Primary Agency Contact Phone: *
Your answer
6. 24/7 Alternate Agency Contact Name:
Your answer
7. 24/7 Alternate Agency Contact E-mail:
Your answer
8. 24/7 Alternate Agency Contact Phone:
Your answer
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