Name of Organization

Question Title

* 1. Name of Organization

Physical Address

Question Title

* 2. Physical Address

Mailing Address

Question Title

* 3. Mailing Address

City

Question Title

* 4. City

Zip Code

Question Title

* 5. Zip Code

EMS Administrator

Question Title

* 6. EMS Administrator

Phone #

Question Title

* 7. Phone #

Fax #

Question Title

* 8. Fax #

Email Address

Question Title

* 9. Email Address

Radio Frequency:

Question Title

* 10. Radio Frequency:

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

Question Title

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

Assistant EMS Administrator

Question Title

* 12. Assistant EMS Administrator

Phone #

Question Title

* 13. Phone #

Fax #

Question Title

* 14. Fax #

Email

Question Title

* 15. Email

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

Question Title

* 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:

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:

Mailing Address:

Question Title

* 18. Mailing Address:

Phone #

Question Title

* 19. Phone #

Fax #

Question Title

* 20. Fax #

Email

Question Title

* 21. Email

Radio Frequency

Question Title

* 22. Radio Frequency

Medical Directors Emergency Contact Number (24/7)

Question Title

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

RAC Representative

Question Title

* 24. RAC Representative

Phone #

Question Title

* 25. Phone #

Phone # that can receive text messages for reminders

Question Title

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

Fax #

Question Title

* 27. Fax #

Email

Question Title

* 28. Email

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

Question Title

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

RAC Alternate Representative

Question Title

* 30. RAC Alternate Representative

Phone #

Question Title

* 31. Phone #

Fax #

Question Title

* 32. Fax #

Email

Question Title

* 33. Email

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

Question Title

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

Tax status of Organization:

Question Title

* 35. Tax status of Organization:

Counties where your organization regularly provides service:

Question Title

* 36. Counties where your organization regularly provides service:

Counties with which you have a contractual agreement?

Question Title

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

Population of your service area

Question Title

* 38. Population of your service area

Square Miles of your service area

Question Title

* 39. Square Miles of your service area

First Responder - # of Ambulances

Question Title

* 40. First Responder - # of Ambulances

First Responder - Staffed 24/7

Question Title

* 41. First Responder - Staffed 24/7

First Responder - Crew on Call

Question Title

* 42. First Responder - Crew on Call

First Responder - Runs per month

Question Title

* 43. First Responder - Runs per month

Basic Life Support - # of Ambulances

Question Title

* 44. Basic Life Support - # of Ambulances

Basic Life Support - Staffed 24/7

Question Title

* 45. Basic Life Support - Staffed 24/7

Basic Life Support - Crew on Call

Question Title

* 46. Basic Life Support - Crew on Call

Basic Life Support - Runs per month

Question Title

* 47. Basic Life Support - Runs per month

BLS with ALS capability - # of Ambulances

Question Title

* 48. BLS with ALS capability - # of Ambulances

BLS with ALS capability - Staffed 24/7

Question Title

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

BLS with ALS capability - Crew on Call

Question Title

* 50. BLS with ALS capability - Crew on Call

BLS with ALS capability - Runs per month

Question Title

* 51. BLS with ALS capability - Runs per month

BLS with MICU capability - # of Ambulances

Question Title

* 52. BLS with MICU capability - # of Ambulances

BLS with MICU capability - Staffed 24/7

Question Title

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

BLS with MICU capability - Crew on Call

Question Title

* 54. BLS with MICU capability - Crew on Call

BLS with MICU capability - Runs per month

Question Title

* 55. BLS with MICU capability - Runs per month

ALS - # of Ambulances

Question Title

* 56. ALS - # of Ambulances

ALS - Staffed 24/7

Question Title

* 57. ALS - Staffed 24/7

ALS - Crew on Call

Question Title

* 58. ALS - Crew on Call

ALS - Runs per month

Question Title

* 59. ALS - Runs per month

ALS with MICU capability - # of Ambulances

Question Title

* 60. ALS with MICU capability - # of Ambulances

ALS with MICU capability - Staffed 24/7

Question Title

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

ALS with MICU capability - Crew on Call

Question Title

* 62. ALS with MICU capability - Crew on Call

ALS with MICU capability - Runs per month

Question Title

* 63. ALS with MICU capability - Runs per month

MICU - # of Ambulances

Question Title

* 64. MICU - # of Ambulances

MICU - Staffed 24/7

Question Title

* 65. MICU - Staffed 24/7

MICU - Crew on Call

Question Title

* 66. MICU - Crew on Call

MICU - Runs per month

Question Title

* 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

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

Do you have a plan to obtain this EQUIPMENT?

Question Title

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

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

Question Title

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

Do you have a plan to obtain his EDUCATION?

Question Title

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

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

Question Title

* 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:

Question Title

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

T