NETPC Needs Assessment Survey

Please fill out each question that is applicable to your agency.

SKIP any question that is not applicable to your agency.

Question Title

* Please select the trauma service area(s) where your facility/office is located:

TSA-F (Counties of Bowie, Cass, Delta, Hopkins, Lamar, Morris, Red River, and Titus)

TSA-G (Counties of Anderson, Camp, Cherokee, Franklin, Freestone, Gregg, Harrison, Henderson, Houston, Marion, Panola, Rains, Rusk, Shelby, Smith, Trinity, Upshur, Van Zandt, and Wood)

Question Title

* Please select your facility or organization type. If you do not appear on the list, select "other" and fill in the blank.

Question Title

* Please enter the following information for your agency:

Agency Name

Parent Company (if applicable)

Address

City/Town

State/Province

ZIP/Postal Code

Question Title

* Please enter the following information regarding the person who is responsible for disaster planning and emergency preparedness:

Name

Title

Department

Position Held for (years and/or months)

Full or Part Time Position

Email Address

Phone Number

Question Title

* Please enter the following information regarding the primary contact for this survey:

Name

Email Address

Phone Number