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Is your agricultural business or rural community site interested in having a rural mobile health event? If so, please complete the following survey.

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* 1. Contact's Name:

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* 2. Contact's Phone Number:

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* 3. Contact's Email:

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* 4. Name of Organization:

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* 5. Event Address (*Please list out full street address):

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* 6. Does your facility have enough space to host a mobile health event?
(*Note: This location should include enough space to accommodate a rural mobile health medical unit. Please allocate a minimum of 4 hours for a mobile health event at your venue, which allows time for set up and delivery of medical services.)

Vehicle Dimensions:
  • The UCSF Fresno RV is 33ft by 9ft wide. This unit can fit in five parking stalls.
  • Fresno State’s Mobile Health Unit in collaboration with Saint Agnes Medical Center: The mobile health unit is 60ft long but will need a total space of 100ft to turn and maneuver.

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* 7. Site Map: Please upload any pictures of the site or a map of the event layout.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 8. Event Accessibility:

*Is this a Public or Private event?

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* 9. Attendance: How many people do you anticipate participating in this event?

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* 10. Event Supplies: Will the event host be able to provide any of the following? (*Please select all that apply)

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* 11. For an event of this type, which day of the week works best for your organization? (*A minimum 2-week lead time is required for requests)

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* 12. Please, provide the top three dates your organization is available for this event?

  Date Time Frame
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2
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* 13. Is this location interested in hosting a reoccurring clinic?

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* 14. Do you have any questions or feedback?

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