Hospital Status Sheet
You can view the data we have collected so far at the following web address:

http://bit.ly/anmf-hospital-status-report
Hospital Information *
Please identify your facility name
Hospital Address Information *
Please provide your facility address
Hospital Type *
Please identify the type of facility you are
Provider Name *
Please provide the name and title of the person providing this information
Provider Contact Information *
Please provide the email and phone number of the person filling in this form
How many Earthquake related patients do you have now
If you can include the severity of the injuries in a general way we would appreciate it. Example. Minor Injuries : 105. You can list fatalities too.
What Physicians do you need
Please break it down for us like Pediatric Surgeon : 2
What other staff do you need
Please break it down for us like Nurses : 9
What Blood supplies do you need by type and quantity
Please break it down for us like AB neg : 100 liters
What Drug supplies do you need by type and quantity
Please break it down for us like Antibiotics : 1000 doses at 50mg
What IV Fluid supplies do you need by type and quantity *
Please break it down for us like Saline Solution : 1000 liters
What Equipment do you need
Please break it down for us like Anesthetic Machine : 2 (capacity note here)
What General Supplies do you need
Please break it down for us like Diesel Fuel : 50 Kl or Water : 500 Kl
Please List any other needs you have
Please use the format Water : 500 Kl
OPTIONAL INFORMATION
If you have time this information would be very helpful to us. If you wish to submit the form scroll to the bottom.
Bed Count (OPTIONAL)
Please give us your bed count in the format - Medical Beds : 54, Surgical Beds : 25, Pediatric Beds: 10. Include ICU, CCU and Other if you can
Physician Count (OPTIONAL)
Please give us your physician count in the format - Surgeons : 15, OB/GYN : 2 covering pediatrics and anesthesiologists as well.
Nurse and other staff Count (OPTIONAL)
Please give us your Nurse and general staff count in the format - Nurses : 15, Orderlies : 6
Operating Rooms (OPTIONAL)
Count of Operating Rooms
Blood Count (OPTIONAL)
In the format AB neg : 200 liters, O neg : 50 liters
Major Drugs (OPTIONAL)
In the format Antibiotics : 200 doses/50mg, etc.
IV Fluids (OPTIONAL)
In the format Saline Solution : 200 liters, etc.
Damage Structurally to Hospital (OPTIONAL)
Please describe the damage to your facility
Accessibility
Please describe the number of roads to your facility and if there are any blocked.
Submit
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