Healthcare Resource Assessment: Public Health
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an event.
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Email *
1. Name of Public Health Department: *
2. Jurisdiction(s) covered (select all that apply): *
Required
3. 24/7 contact for your agency - Name (can enter name of 24/7 phone line, if applicable): *
4. 24/7 contact for your agency - Phone: *
5. 24/7 contact for your agency - E-mail: *
6. 24/7 alternate contact for your agency - Name:
7. 24/7 alternate contact for your agency - Phone:
8. 24/7 alternate contact for your agency - E-mail:
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