Healthcare Organization Survey re: Haitian Earthquake Response

Exit this survey

1. Haitian Earthquake Response

1. Healthcare organization name

Healthcare organization name

2. Name of person completing survey. DPH may contact you with questions.

Name of person completing survey. DPH may contact you with questions.

3. Phone number

Phone number

4. Fax number

Fax number

5. Email address

Email address

6. Type of healthcare facility

Type of healthcare facility Hospital

Community Health Center

Long-term Care

Other

7. Is your healthcare organization able and willing to donate medications and/or supplies? If yes, proceed to questions 8 and 9.

Is your healthcare organization able and willing to donate medications and/or supplies? If yes, proceed to questions 8 and 9. Yes

8. Quantities of medications that your healthcare organization would be able to donate. For example, 100 doses of x medication.

Quantities of medications that your healthcare organization would be able to donate. For example, 100 doses of x medication. Bupivaine
Fentanyl
Katmine
Midazolam
Thiopental
Amoxiciline 500 ml
ceftriaxone IM
codine 30 mg
Dextrose 5 percent solution
diazepam 10 mg
Diclofenac sodium 75 mg injection
Lidocane 50ml injection
Mannitriol IV solution
Morphine tablets
Paracetemol
Sodium chloride IV solution 9 percent
Tetanus vaccine
Vivonex
Other - please specify

9. Quantities of supplies that your healthcare organization would be willing to donate. For example, 50 boxes of x supplies.

Quantities of supplies that your healthcare organization would be willing to donate. For example, 50 boxes of x supplies. LMA laryngeal mask area
Spinal kits
Adhesive tape
Alcohol antiseptic bottles
Bandages – elastic
Bandages – gauze pads
Cotton
Gloves
Hand Sanitizer
IV tubing supplies
Iodine
Masks (N-95)
Masks (Surgical)
Nutritional Supplements
Ortho materials – splints, casting
Oxygen
Surgical blades
Surgical drapes
Surgical packs
Surgical instruments
Syringes
Bottled Water
Flashlights
Sleeping Bags
Tents
Other - please specify

10. Does your healthcare organization have the ability to securely package and transport the supplies it would be willing to donate within the following areas:

Does your healthcare organization have the ability to securely package and transport the supplies it would be willing to donate within the following areas: Locally? (within 50 miles of your organization)

Statewide? (anywhere within Massachusetts)