Fresno County Rural Mobile Health Event Survey

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Are you 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. Please note that event requests should be submitted at least 4 weeks in advance of the event date. Priority is given to agricultural workplaces and people living in disadvantaged areas within Fresno County.

If you have any questions, please email DPHMobileHealth@FresnoCountyCA.gov or call (559) 600-4063.

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. Only one mobile health unit will be onsite at each rural mobile health event. 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.

Yes

Other:

Event Accessibility:

*Is this a Public or Private event?
*

Private

Public

Attendance: How many people do you anticipate participating in this event?
*

1 - 49

50 - 99

100-150 (the maximum number of people that the medical providers can screen is 150 per day. If needed, the medical team can work with the event host to schedule more mobile health events at the site in order to screen more individuals)

Event Supplies: Will the event host be able to provide any of the following? Access to restrooms is required. (*Please select all that apply.)
*

Chairs (10-25 chairs)

Tables (1-4 tables)

Canopies (1-3 canopies)

WiFi

Water / Water Hose

Electricity / Outlets

Restrooms

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. Limited availability on Saturdays and Sundays. A minimum 4-week lead time is required for requests.

YYYY

Time

Please include the end time for the event. *

Time

Is this a back to school event? *

Yes

Do you have any questions?

Submit

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