FCAT_012017 Question Title * 1. Please select the Healthcare Coalition in which your facility is located: Mountain Area Healthcare Preparedness Coalition (MAHPC) Triad Healthcare Preparedness Coalition (WFU Baptist/Moses Cone) Metrolina Healthcare Preparedness Coalition (Carolinas Medical Center) Duke Healthcare Preparedness Coalition (Duke University Hospital) Mid Carolina Regional Healthcare Coalition (UNC Healthcare) Capital RAC (WAKEMED) Eastern Healthcare Preparedness Coalition (Vidant Medical Center) Southeastern Healthcare Preparedness Region (New Hanover Regional) Question Title * 2. Facility Name Facility Street Address 1 Facility Street Address 2 City State Zip Code Question Title * 3. Contact Person for infrastructure assessment questions Name Email Address Phone number Question Title * 4. Please identify your facility type Assisted living/personal care home Behavioral Health in-patient Critical Access Hospital Hospital (with ED) Freestanding Emergency Room Inpatient Hospice Long-term Acute Care Other (please specify) Question Title * 5. Identify your Primary Essential Functions (select all that apply) Burn Critical Care Beds Decontamination Diagnostic Procedures Emergency Department Inpatient Beds Isolation Laboratory Services Negative Pressure OB Operating Room Orthopedic Pediatrics Pharmacy PT/OT Radiology Respiratory Therapy Nursery/Special Care nursery Trauma Center Next