Pre-Hospital Needs Assessment Question Title * 1. Name of Organization Question Title * 2. Physical Address Question Title * 3. Mailing Address Question Title * 4. City Question Title * 5. Zip Code Question Title * 6. EMS Administrator Question Title * 7. Phone # Question Title * 8. Fax # Question Title * 9. Email Address Question Title * 10. Radio Frequency: Question Title * 11. EMS Administrator's Emergency Contact Number (24/7) Question Title * 12. Assistant EMS Administrator Question Title * 13. Phone # Question Title * 14. Fax # Question Title * 15. Email Question Title * 16. Assistant EMS Administrator's Emergency Contact Number (24/7) Question Title * 17. (Please list the contact information for your Medical Director. DO NOT list the address and phone numbers for your organization as contact info for your Medical Director.) Medical Director: Question Title * 18. Mailing Address: Question Title * 19. Phone # Question Title * 20. Fax # Question Title * 21. Email Question Title * 22. Radio Frequency Question Title * 23. Medical Directors Emergency Contact Number (24/7) Question Title * 24. RAC Representative Question Title * 25. Phone # Question Title * 26. Phone # that can receive text messages for reminders Question Title * 27. Fax # Question Title * 28. Email Question Title * 29. RAC Representative's Emergency Contact Number (24/7) Question Title * 30. RAC Alternate Representative Question Title * 31. Phone # Question Title * 32. Fax # Question Title * 33. Email Question Title * 34. RAC Alternate Representative's Emergency Contact Number (24/7) Question Title * 35. Tax status of Organization: Question Title * 36. Counties where your organization regularly provides service: Question Title * 37. Counties with which you have a contractual agreement? Question Title * 38. Population of your service area Question Title * 39. Square Miles of your service area Question Title * 40. First Responder - # of Ambulances Question Title * 41. First Responder - Staffed 24/7 Yes No Question Title * 42. First Responder - Crew on Call Yes No Question Title * 43. First Responder - Runs per month Question Title * 44. Basic Life Support - # of Ambulances Question Title * 45. Basic Life Support - Staffed 24/7 Yes No Question Title * 46. Basic Life Support - Crew on Call Yes No Question Title * 47. Basic Life Support - Runs per month Question Title * 48. BLS with ALS capability - # of Ambulances Question Title * 49. BLS with ALS capability - Staffed 24/7 Yes No Question Title * 50. BLS with ALS capability - Crew on Call Yes No Question Title * 51. BLS with ALS capability - Runs per month Question Title * 52. BLS with MICU capability - # of Ambulances Question Title * 53. BLS with MICU capability - Staffed 24/7 Yes No Question Title * 54. BLS with MICU capability - Crew on Call Yes No Question Title * 55. BLS with MICU capability - Runs per month Question Title * 56. ALS - # of Ambulances Question Title * 57. ALS - Staffed 24/7 Yes No Question Title * 58. ALS - Crew on Call Yes No Question Title * 59. ALS - Runs per month Question Title * 60. ALS with MICU capability - # of Ambulances Question Title * 61. ALS with MICU capability - Staffed 24/7 Yes No Question Title * 62. ALS with MICU capability - Crew on Call Yes No Question Title * 63. ALS with MICU capability - Runs per month Question Title * 64. MICU - # of Ambulances Question Title * 65. MICU - Staffed 24/7 Yes No Question Title * 66. MICU - Crew on Call Yes No Question Title * 67. MICU - Runs per month Question Title * 68. RAC-D can offer assistance to its members through RAC wide projects. It can also offer advice and assistance in carrying out injury prevention activities. With that in mind please list your needs below:Please list EQUIPMENT needed in order or priority Question Title * 69. Do you have a plan to obtain this EQUIPMENT? Question Title * 70. Please list EDUCATION needed (include course , training equipment and # of students needing training) Question Title * 71. Do you have a plan to obtain his EDUCATION? Question Title * 72. Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience) Question Title * 73. Use the space below to provide details concerning your needs and how the RAC might assist you: Done
