Basic Health Care Facility Information
DO NOT MAIL A COPY OF YOUR PLAN
Update and submit this form annually to the Shelby County Office of Preparedness
Non-emergency number: (901) 222-6700
Email address *
Reporting Year *
Name of Person Completing Form *
Your answer
ABOUT THE FACILITY
Type of Facility *
(nursing home, dialysis, outpatient, supply distribution, call-center, etc.)
Facility Name *
Your answer
Facility Phone *
Your answer
Facility Fax *
Your answer
Facility Street Address *
Physical location of facility
Your answer
Facility Street Address 2
(Building number, Suite number, etc.)
Your answer
Facility City *
Your answer
Facility Zip *
Your answer
Type of Building
(single building, multi-office complex, warehouse, etc.)
Your answer
Number of Beds at the Facility *
if none, enter 0
Your answer
Number of Full-Time Employees *
if none, enter 0
Your answer
Number of Part-Time Employees *
if none, enter 0
Your answer
Number of Vehicles Available for Emergency Evacuation *
if none, enter 0
Your answer
Name of Your Facility's Paired Facility (Back-up) *
if none, enter 0
Your answer
This Facility Has an Emergency Generator *
Emergency Contacts
(Delegation / Succession)
Emergency Contact Name 1 *
Your answer
Emergency Work Phone 1 *
Your answer
Emergency Cell Phone 1 *
Your answer
Emergency Home Phone or Pager 1
Your answer
Emergency Address 1
Your answer
Emergency City/State 1
Your answer
Emergency Contact Name 2 *
Your answer
Emergency Work Phone 2 *
Your answer
Emergency Cell Phone 2 *
Your answer
Emergency Home Phone or Pager 2
Your answer
Emergency Address 2
Your answer
Emergency City/State 2
Your answer
A copy of your responses will be emailed to the address you provided.
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