Is Your Hospital Prepared for the Ebola Virus?

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* 1. Hospital/facility information

Hospital/facility:

Unit:

City:

State:

ZIP:

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* 2. Your name and contact info:

Name:

Email Address:

Phone Number:

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* 3. CNA/NNOC member?

Yes

No

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* 4. NNU member?

Yes

No

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* 5. RNRN member?

Yes

No

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* 6. Has your hospital/facility communicated to you any policies regarding potential admission of patients with Ebola?

Yes

No

Don’t know/not applicable