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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1. Name of agency: *
2. Location of facility/facilities (county) - select all that apply: *
Required
3. 24/7 primary agency contact - Name: *
4. 24/7 primary agency contact - Phone: *
5. 24/7 primary agency contact - E-mail: *
6. Facility type(s) - select all that apply: *
Required
7. Total number of beds in your facility - please specify type of beds, if needed:
8. Does your facility provide residential (over night) services?
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