Region E Needs Assessment - January 2023 Question Title * 1. First Name: Question Title * 2. Last Name: Question Title * 3. Contact email: Question Title * 4. Contact Phone Number: Question Title * 5. Facility/Organization Name Question Title * 6. Type of response agency EMS EMA Hospital Nursing Home Assisted Living Personal Care Home Dialysis Clinic Home Health Behavioral Health Public Safety Schools or Universities Outpatient Health Care Delivery Other (please specify) Question Title * 7. Equipment/Training/Supplies Needed Question Title * 8. Description Question Title * 9. Need identified is for the following response Natural Disaster Man Made Disaster Hurricane Tornado Disaster Equipment PPE Training Biological Response Chemical Response Severe Weather Ice Storm Active Threat Civil Unrest Other (please specify) Question Title * 10. How was need identified? Exercise Real World Event Response Plan Other (please specify) Question Title * 11. Justification of Equipment/Training/Supplies Needed Question Title * 12. Name/Vendor/Item number (include link) Question Title * 13. Estimated Cost of item If you have more than one need identified please complete the survey again. Done