General and Background Information

1. General and Background Information

Question Title

* 1. Please enter facility name and location.

Facility Name:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Question Title

* 2. Please provide the names of any other health organizations (national or international) that serve your community.

Question Title

* 3. Who will be RAD-AID™'s primary contact person at your facility?

Name:

Title:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address:

Phone Number:

Question Title

* 4. Facility ownership and affiliations. Select all that apply.

Public/government

Privately owned

Corporate

Non-profit

University affiliated

Religious entity or religious charity

Other

If Other, please specify

Question Title

* 5. How would you classify your facility? Please select the single best classification.

Tertiary referral center

Community or district hospital

Community health center or ambulatory clinic

Free-standing imaging center

Small health post or village clinic

Other

If Other, please specify

Question Title

* 6. What is the approximate size of the population served by your facility?

Question Title

* 7. Please list the top three challenges faced by your facility in order of importance. Please explain the nature of each challenge and why it is particularly problematic for your facility.

Page1 / 2

50% of survey complete.