Healthcare Resource Assessment: Emergency Management (Responses)
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TimestampEmail Address1. Name of Agency:
2. Jurisdiction(s) Served (select all that apply):
3. 24/7 primary contact: Name
4. 24/7 primary contact: Phone
5. 24/7 primary contact: E-mail
6. 24/7 alternate contact: Name
7. 24/7 alternate contact: Phone
8. 24/7 alternate contact: E-mail
9. Please upload any medical supply cache inventory list(s), and locations, to the following Google folder: https://drive.google.com/drive/folders/1AZ5CBPBORXjvDkHKFwXUUQVBu-kUm2M9?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your cache inventory list to SWCHCC@gmail.com.
10. Please describe your medical supply cache mobilization processes, including: activation process, chain of custody, restocking requirements, etc. If already documented, please upload to the following Google folder: https://drive.google.com/drive/folders/1GOLupF-Gd7BMaROE9CCren-NL-GsP3f8?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your cache mobilization process to SWCHCC@gmail.com.
11. What resource tracking system (MultiCard, Salamander) does your agency use?
12. Please indicate which web-based systems your agency utilizes:
14. Supply/piece of equipment #1: Type
15. Supply/piece of equipment #1: Quantity
16. Supply/piece of equipment #2: Type
17. Supply/piece of equipment #2: Quantity
18. Supply/piece of equipment #3: Type
19. Supply/piece of equipment #3: Quantity
20. Supply/piece of equipment #4: Type
21. Supply/piece of equipment #4: Quantity
22. Supply/piece of equipment #5: Type
23. Supply/piece of equipment #5: Quantity
24. Supply/piece of equipment #6: Type
25. Supply/piece of equipment #6: Quantity
26. Supply/piece of equipment #7: Type
27. Supply/piece of equipment #7: Quantity
28. Please identify which communication modalities your agency currently supports (select all that apply):
29. Please select all radio capabilities currently available within your agency:
30. Number of portable or mobile radios that support interoperable communications within the Southwest Region:
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