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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.
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Email
*
Your email
1. Name of Agency:
*
Your answer
2. Jurisdiction(s) Served (select all that apply):
*
Pueblo
Fremont
Huerfano
Custer
Las Animas
Other:
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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