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Healthcare Resource Assessment - EMS
This survey is designed to collect information on disaster-related assets within your agency
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Email
*
Your email
1. Agency Name:
*
Your answer
2. Jurisdiction(s) Covered (please select all that apply):
*
Alamosa
Conejos
Costilla
Mineral
Rio Grande
Saguache
Other:
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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