Facility Details

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1. Please select your facility name and CCN: (Required.)

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2. Person completing questionnaire: (Required.)

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3. Select the best description/setting of your facility: (Required.)

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4. Does your facility have on-site parking? (Required.)

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5. Is free parking available? (Required.)

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6. What area hospitals do your patients use? (Required.)

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7. What is the average amount of time it takes your patients to travel to a hospital? (Required.)

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8. How many staff members are in your facility? (Required.)

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9. Is your facility currently short staffed? (Required.)

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