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Healthcare Resource Assessment: Emergency Management
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an emergency.
Email address *
1. Name of Agency: *
Your answer
2. Jurisdiction(s) Served (select all that apply): *
Required
3. 24/7 primary contact: Name *
Your answer
4. 24/7 primary contact: Phone *
Your answer
5. 24/7 primary contact: E-mail *
Your answer
6. 24/7 alternate contact: Name
Your answer
7. 24/7 alternate contact: Phone
Your answer
8. 24/7 alternate contact: E-mail
Your answer
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