Sexual Assault Exam Equipment Question Title * 1. IHS Area Aberdeen Alaska Albuquerque Bemidji Billings California Nashville Navajo Oklahoma Phoenix Portland Tucson Question Title * 2. Name of Facility Question Title * 3. Is your facility federally operated or Tribally operated? IHS or federally operated Tribally operated Question Title * 4. Please provide the following information: Name of Person filling out Request: Email of Person filling out Request: Facility Chief Executive Officer Facility CEO email address Facility Chief Medical Officer Facility Chief Medical Officer email address Facility Chief Nursing Officer Facility Chief Nursing Officer email address Physical Street Address City State Zipcode Phone Number Question Title * 5. Does your facility need new forensic equipment to conduct sexual assault exams? Yes No Next