Facility Demographics

Note that this is a two page survey. please click next at the bottom of this page to answer participation questions. 

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* 1. Contact Name

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* 2. Facility Name

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* 3. Facility Address

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* 4. Email

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* 5. Please define your facility type: If you provide more than one service, choose all that apply

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* 6. Facility Chapter

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* 7. Our facility will participate in this exercise

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* 8. Our facility has a command center

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* 9. Our facility has access to the SDHCC eICS Command tool

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* 10. Our facility has been trained in Incident Command

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* 11. Our facility has participated in at least one previous SDHCC Statewide Exercise

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* 12. This exercise will give facilities the opportunity to test their internal plans. A facility can choose to be either an affected facility, where decision making would involve protecting in place or evacuation/ relocation capabilities, OR, being a receiving facility where decision making would include increasing capacity to receive evacuated patients. Please choose which tasks you would like your facility to work through during the exercise. (Note that all task sheets will be made available after the exercise). Please be advised that we will try to accommodate your first choice. We need approximately 10 facilities to evacuate.

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* 13. A pre-event briefing will be held on 10/12 at 10AM CT. This briefing will outline the exercise and expectations. This brief will be very helpful to new partner facilities.

Our facility will attend the pre-event breifing on 10/12 at 10AM

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