Survey Instructions / What to Expect

If you have already registered and requested information or received an email with login instructions after 04/03/2020:  Click HERE to login.

If you have not set up an account, Start HERE:

1.  Please fill out this survey with your contact information and submit it.

2.  Once we receive your request we will add you to our COVID-19 Daily Counts & Equipment Requests application

3.  During normal business hours you will then, within 2 hours, receive an email with a link to this system, including your login and password information.  Responses submitted after 4:30pm will be processed the next morning between 8-10am.  This will only need to be done one time.

4.  Upon receiving this email follow its instructions to login and utilize the system daily.

If you have any questions, please call (402) 441-9400.
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* 1. Facility Name

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* 2. Enter Your Email Address - Required for Login Credentials

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* 3. Full Name

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* 4. Position Title

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* 5. Primary Phone

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* 6. Secondary Phone

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* 7. Fax

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* 8. Address

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* 9. Delivery Address

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* 10. City

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* 11. State

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* 12. Zip Code

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