Find your regional healthcare coalition and/or local Emergency Manager

Question Title

* 1. Your facility and contact information

Your name

Your facility name

Facility address

Address 2

City

State

ZIP

Your title

Your email address

Best phone number to reach you

Question Title

* 2. Please give me information on my:

Regional Healthcare Coalition

Local (city or county) Emergency Management Coordinator

Both

Other (please specify)

Question Title

* 3. How many total patients/residents is the capacity of your facility?

fewer than 40

40 to 99

100 or more

Question Title

* 4. What type of facility is this?

Other/more than one (please specify)

Question Title

* 5. Thanks. We'll match your data to our database and get back to you, usually within one business day, with your information. If you have further questions, please ask them below.