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General and Background Information
2.
General and Background Information
1.
Please enter facility name and location.
Facility Name:
Address 1:
Address 2:
City/Town:
State/Province:
ZIP/Postal Code:
Country:
2.
Please provide the names of any
other health organizations
(national or international) that serve your community.
3.
Who will be RAD-AID™'s
primary contact person
at your facility?
Name:
Title:
Address 1:
Address 2:
City/Town:
State/Province:
ZIP/Postal Code:
Country:
Email Address:
Phone Number:
4.
Facility ownership and affiliations.
Select all that apply.
Public/government
Privately owned
Corporate
Non-profit
University affiliated
Religious entity or religious charity
Other
If Other, please specify
5.
How would you classify your facility?
Please select the single best classification.
Tertiary referral center
Community or district hospital
Community health center or ambulatory clinic
Free-standing imaging center
Small health post or village clinic
Other
If Other, please specify
6.
What is the approximate size of the population served by your facility?
7.
Please list the
top three challenges faced by your facility
in order of importance. Please explain the nature of each challenge and why it is particularly problematic for your facility.
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