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* 1. What health center are you affiliated with?

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

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

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* 4. Please list any health center sites that are closed due to the riots.

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

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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.

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

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