Fresno County Rural Mobile Health Event Survey
Is your agricultural business or rural community site interested in having a rural mobile health event? If so, please complete the following survey. Upon completion a member of our team will follow up with you.

If you have any questions, please email DPHMobileHealth@FresnoCountyCA.gov or call (559) 600-4063.
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Contact's Name: *
Contacts Phone Number: *
Contact's Email: *
Name of Organization: *
Event Address (*Please list out full street address):  
 *
Does your facility have enough space to host a rural mobile health event?

(*Note: This location should include enough space to accommodate a mobile health unit. Please allocate a minimum of 4 hours for a rural mobile health event at your venue, which allows time for set up and delivery of medical services, including: registration area, screening area, and a health education table for community health workers (CHWs) to provide information.)

Vehicle Dimensions:
The UCSF Fresno RV is 33ft by 9ft wide. This unit can fit in five parking stalls. 

Saint Agnes Medical Center's mobile health unit is 60ft long but will need a total space of 100ft to turn and maneuver. *Only one mobile health unit will be onsite at each rural mobile health event
 *
Event Accessibility:

*Is this a Public or Private event?  
 *
Attendance: How many people do you anticipate participating in this event?  
 *
Event Supplies: Will the event host be able to provide any of the following? (*Please select all that apply)  
 *
Required
For an event of this type, which day of the week works best for your organization? (*A minimum 2-week lead time is required for requests)  
 *
Required
Please, provide a date your organization is available for this event?

*The medical team will do their best to accommodate these requests based on their availability, Sundays are not available.
 *
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Is this location interested in hosting a reoccurring clinic?  
 *
Do you have any questions or feedback?  
Is this a back to school event? *
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