Foothills Healthcare Coalition

Thank you for participating in the Foothills Healthcare Coalition survey. Please complete this survey from the perspective of the agency* you represent on the healthcare coalition. If you have any questions, please contact Kelly Forster([email protected]).

Thanks so much for your time!

*We are using the term agency to refer to any association, business, club, company, department, firm, group, institue, orgnaization, society, ect.

First Name :

Last Name :

* Agency :

Title :

* City :

* State :

* Zip :

Phone :

Email Address :

* Please select the answer that best describes your agency

Government

Private, for-profit

Private, not-for-profit or non-profit

Other

How many hours per day is your agency open (providing services)?

Less than 8 hours a day

8-12 hours a day

12-23 hours a day

24 hours a day

How often is your agency open (providing services)?

Less than 5 days a week

5 days a week

6 days a week

7 days a week, except major holidays

7 days a week, 365 days a year

Other

* Please select any of the following descriptions that indicate the type of services your agency provides. Please note that you may select more than one response and that several of the choices may be contained in other descriptions.

* Please select the description that best indicates the population your agency serves. Please note that you may select more than one description.

* Briefly describe your agency roles and responsibilities during an emergency for/to the population your agency serves.

* In an large-scale emergency, like a major blizzard or terrorist attack, would your agency:

Remain open and in full operations

Remain open with limited operations

Likely close (e.g. call a snow day) however staff should be reachable (on call)

Likely close (e.g. call a snow day) all operations

Other

Please select all of the following statements that apply to your agency.