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FCAT_012017
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)
2.
Facility Name
Facility Street Address 1
Facility Street Address 2
City
State
Zip Code
3.
Contact Person for infrastructure assessment questions
Name
Email Address
Phone number
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)
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