Pre-Hospital Needs Assessment Survey

EMS Administrator's Emergency Contact Number (24/7)

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* 11. EMS Administrator's Emergency Contact Number (24/7)

Assistant EMS Administrator

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* 12. Assistant EMS Administrator

Phone #

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* 13. Phone #

Fax #

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* 14. Fax #

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* 15. Email

Assistant EMS Administrator's Emergency Contact Number (24/7)

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* 16. Assistant EMS Administrator's Emergency Contact Number (24/7)

(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:

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* 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:

Mailing Address:

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* 18. Mailing Address:

Phone #

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* 19. Phone #

Fax #

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* 20. Fax #

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* 21. Email

Radio Frequency

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* 22. Radio Frequency

Medical Directors Emergency Contact Number (24/7)

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* 23. Medical Directors Emergency Contact Number (24/7)

RAC Representative

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* 24. RAC Representative

Phone #

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* 25. Phone #

Phone # that can receive text messages for reminders

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* 26. Phone # that can receive text messages for reminders

Fax #

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* 27. Fax #

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* 28. Email

RAC Representative's Emergency Contact Number (24/7)

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* 29. RAC Representative's Emergency Contact Number (24/7)

RAC Alternate Representative

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* 30. RAC Alternate Representative

Phone #

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* 31. Phone #

Fax #

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* 32. Fax #

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* 33. Email

RAC Alternate Representative's Emergency Contact Number (24/7)

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* 34. RAC Alternate Representative's Emergency Contact Number (24/7)

Tax status of Organization:

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* 35. Tax status of Organization:

Counties where your organization regularly provides service:

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* 36. Counties where your organization regularly provides service:

Counties with which you have a contractual agreement?

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* 37. Counties with which you have a contractual agreement?

Population of your service area

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* 38. Population of your service area

Square Miles of your service area

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* 39. Square Miles of your service area

First Responder - # of Ambulances

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* 40. First Responder - # of Ambulances

First Responder - Staffed 24/7

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* 41. First Responder - Staffed 24/7

Yes

First Responder - Crew on Call

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* 42. First Responder - Crew on Call

Yes

First Responder - Runs per month

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* 43. First Responder - Runs per month

Basic Life Support - # of Ambulances

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* 44. Basic Life Support - # of Ambulances

Basic Life Support - Staffed 24/7

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* 45. Basic Life Support - Staffed 24/7

Yes

Basic Life Support - Crew on Call

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* 46. Basic Life Support - Crew on Call

Yes

Basic Life Support - Runs per month

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* 47. Basic Life Support - Runs per month

BLS with ALS capability - # of Ambulances

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* 48. BLS with ALS capability - # of Ambulances

BLS with ALS capability - Staffed 24/7

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* 49. BLS with ALS capability - Staffed 24/7

Yes

BLS with ALS capability - Crew on Call

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* 50. BLS with ALS capability - Crew on Call

Yes

BLS with ALS capability - Runs per month

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* 51. BLS with ALS capability - Runs per month

BLS with MICU capability - # of Ambulances

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* 52. BLS with MICU capability - # of Ambulances

BLS with MICU capability - Staffed 24/7

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* 53. BLS with MICU capability - Staffed 24/7

Yes

BLS with MICU capability - Crew on Call

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* 54. BLS with MICU capability - Crew on Call

Yes

BLS with MICU capability - Runs per month

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* 55. BLS with MICU capability - Runs per month

ALS - # of Ambulances

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* 56. ALS - # of Ambulances

ALS - Staffed 24/7

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* 57. ALS - Staffed 24/7

Yes

ALS - Crew on Call

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* 58. ALS - Crew on Call

Yes

ALS - Runs per month

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* 59. ALS - Runs per month

ALS with MICU capability - # of Ambulances

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* 60. ALS with MICU capability - # of Ambulances

ALS with MICU capability - Staffed 24/7

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* 61. ALS with MICU capability - Staffed 24/7

Yes

ALS with MICU capability - Crew on Call

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* 62. ALS with MICU capability - Crew on Call

Yes

ALS with MICU capability - Runs per month

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* 63. ALS with MICU capability - Runs per month

MICU - # of Ambulances

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* 64. MICU - # of Ambulances

MICU - Staffed 24/7

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* 65. MICU - Staffed 24/7

Yes

MICU - Crew on Call

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* 66. MICU - Crew on Call

Yes

MICU - Runs per month

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* 67. MICU - Runs per month

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

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* 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

Do you have a plan to obtain this EQUIPMENT?

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* 69. Do you have a plan to obtain this EQUIPMENT?

Please list EDUCATION needed (include course , training equipment and # of students needing training)

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* 70. Please list EDUCATION needed (include course , training equipment and # of students needing training)

Do you have a plan to obtain his EDUCATION?

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* 71. Do you have a plan to obtain his EDUCATION?

Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)

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* 72. Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)

Use the space below to provide details concerning your needs and how the RAC might assist you:

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* 1. Name of Organization

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* 2. Physical Address

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* 3. Mailing Address

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* 4. City

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* 5. Zip Code

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* 6. EMS Administrator

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* 7. Phone #

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* 8. Fax #

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* 9. Email Address

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* 10. Radio Frequency:

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* 11. EMS Administrator's Emergency Contact Number (24/7)

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* 12. Assistant EMS Administrator

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* 13. Phone #

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* 14. Fax #

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* 15. Email

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* 16. Assistant EMS Administrator's Emergency Contact Number (24/7)

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* 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:

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* 18. Mailing Address:

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* 19. Phone #

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* 20. Fax #

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* 21. Email

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* 22. Radio Frequency

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* 23. Medical Directors Emergency Contact Number (24/7)

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* 24. RAC Representative

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* 25. Phone #

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* 26. Phone # that can receive text messages for reminders

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* 27. Fax #

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* 28. Email

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* 29. RAC Representative's Emergency Contact Number (24/7)

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* 30. RAC Alternate Representative

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* 31. Phone #

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* 32. Fax #

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* 33. Email

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* 34. RAC Alternate Representative's Emergency Contact Number (24/7)

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* 35. Tax status of Organization:

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* 36. Counties where your organization regularly provides service:

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* 37. Counties with which you have a contractual agreement?

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* 38. Population of your service area

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* 39. Square Miles of your service area

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* 40. First Responder - # of Ambulances

* 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:

* 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