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Healthcare Resource Assessment - Ancillary Healthcare
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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* Indicates required question
Email
*
Your email
1. Name of agency:
*
Your answer
2. Location of facility/facilities (county) - select all that apply:
*
Custer County
Fremont County
Huerfano County
Las Animas County
Pueblo County
Required
3. 24/7 primary agency contact - Name:
*
Your answer
4. 24/7 primary agency contact - Phone:
*
Your answer
5. 24/7 primary agency contact - E-mail:
*
Your answer
6. Facility type(s) - select all that apply:
*
Ambulatory Surgery Center
Assisted Living
Dialysis
Home Health
Hospice
Long Term Care
Skilled Nursing Center
Federally Qualified Health Center
Clinic
Rehabilitation Facility
Continuing Care Retirement Community (CCRC)
Other:
Required
7. Total number of beds in your facility - please specify type of beds, if needed:
Your answer
8. Does your facility provide residential (over night) services?
Yes
No
Other:
Clear selection
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