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* 1. Name of Agency

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* 2. Address of Agency

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* 3. What County does your agency reside in?

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* 4. Agency Point of Contact Name

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* 5. Agency Point of Contact Contact Email Address

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* 6. Number of Staff at your Agency

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* 7. Number of BLS Ambulances at your Agency

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* 8. Number of ALS Ambulances at your Agency

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* 9. Does your Agency currently use OHTrac?

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* 10. If your Agency has an OHTrac account and doesn't use it please select why.

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* 11. If you have Trained Staff at your Agency why are they not using OHTrac?

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* 12. Will your Agency continue to use or if you're not using use OHTrac in the future?

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* 13. If you have previously used OHTrac, do you feel the training materials will change how you use it? 

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* 14. If you don't plan to use OHTrac in your Agency, please select why?

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* 15. Does your Agency plan to conduct or participate in drills using OHTrac

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* 16. Why will your Agency not use OHTrac during drills/exercises?

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* 17. Please add any additional comments or barriers related to OHTrac. 

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* 18. Please type your full name to indicate that you are aware that OHTrac exists in the State of Ohio, and to acknowledge that if your Agency wants to use OHTrac a Confidentiality Form will need to be signed by your Agency Head.

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