NETPC Needs Assessment Survey Please fill out each question that is applicable to your agency. SKIP any question that is not applicable to your agency. OK Question Title * Please select the trauma service area(s) where your facility/office is located: TSA-F (Counties of Bowie, Cass, Delta, Hopkins, Lamar, Morris, Red River, and Titus) TSA-G (Counties of Anderson, Camp, Cherokee, Franklin, Freestone, Gregg, Harrison, Henderson, Houston, Marion, Panola, Rains, Rusk, Shelby, Smith, Trinity, Upshur, Van Zandt, and Wood) OK Question Title * Please select your facility or organization type. If you do not appear on the list, select "other" and fill in the blank. EMS Hospital Critical Access Hospital Long Term Care Home Health Hospice Federally Qualified Health Center/Rural Health Clinic End-Stage Renal Disease Other (please specify) OK Question Title * Please enter the following information for your agency: Agency Name Parent Company (if applicable) Address City/Town State/Province ZIP/Postal Code OK Question Title * Please enter the following information regarding the person who is responsible for disaster planning and emergency preparedness: Name Title Department Position Held for (years and/or months) Full or Part Time Position Email Address Phone Number OK Question Title * Please enter the following information regarding the primary contact for this survey: Name Email Address Phone Number OK NEXT