Pre-Hospital Needs Assessment

1.Name of Organization
2.Physical Address
3.Mailing Address
4.City
5.Zip Code
6.EMS Administrator
7.Phone #
8.Fax #
9.Email Address
10.Radio Frequency:
11.EMS Administrator's Emergency Contact Number (24/7)
12.Assistant EMS Administrator
13.Phone #
14.Fax #
15.Email
16.Assistant EMS Administrator's Emergency Contact Number (24/7)
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:
18.Mailing Address:
19.Phone #
20.Fax #
21.Email
22.Radio Frequency
23.Medical Directors Emergency Contact Number (24/7)
24.RAC Representative
25.Phone #
26.Phone # that can receive text messages for reminders
27.Fax #
28.Email
29.RAC Representative's Emergency Contact Number (24/7)
30.RAC Alternate Representative
31.Phone #
32.Fax #
33.Email
34.RAC Alternate Representative's Emergency Contact Number (24/7)
35.Tax status of Organization:
36.Counties where your organization regularly provides service:
37.Counties with which you have a contractual agreement?
38.Population of your service area
39.Square Miles of your service area
40.First Responder - # of Ambulances
41.First Responder - Staffed 24/7
42.First Responder - Crew on Call
43.First Responder - Runs per month
44.Basic Life Support - # of Ambulances
45.Basic Life Support - Staffed 24/7
46.Basic Life Support - Crew on Call
47.Basic Life Support - Runs per month
48.BLS with ALS capability - # of Ambulances
49.BLS with ALS capability - Staffed 24/7
50.BLS with ALS capability - Crew on Call
51.BLS with ALS capability - Runs per month
52.BLS with MICU capability - # of Ambulances
53.BLS with MICU capability - Staffed 24/7
54.BLS with MICU capability - Crew on Call
55.BLS with MICU capability - Runs per month
56.ALS - # of Ambulances
57.ALS - Staffed 24/7
58.ALS - Crew on Call
59.ALS - Runs per month
60.ALS with MICU capability - # of Ambulances
61.ALS with MICU capability - Staffed 24/7
62.ALS with MICU capability - Crew on Call
63.ALS with MICU capability - Runs per month
64.MICU - # of Ambulances
65.MICU - Staffed 24/7
66.MICU - Crew on Call
67.MICU - Runs per month
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
69.Do you have a plan to obtain this EQUIPMENT?
70.Please list EDUCATION needed (include course , training equipment and # of students needing training)
71.Do you have a plan to obtain his EDUCATION?
72.Please list PUBLIC INJURY PREVENTION needed (include Program, Equipment needed, supplies needed & target audience)
73.Use the space below to provide details concerning your needs and how the RAC might assist you: