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1. What health center are you affiliated with? (Required.)

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2. Please provide us with a Point of Contact, their Phone number and Email id. (Required.)

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3. In light of the Baltimore riots, how many of your health center sites have been impacted? (Required.)

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4. Please list any health center sites that are closed due to the riots. (Required.)

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5. Did the riots so far, result in any property damages? If yes, please list which sites. (Required.)

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6. Have you notified the following groups regarding any site closings, damages or concerns?

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7. What are your needs or concerns at this time? Please provide a detailed response below. (Required.)

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8. How are you communicating with your staff and patients to cancel appointments should the closures affect their appointments? (Required.)

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