MitechOne | Site Survey
Complete one form per location
Organization
Organization Name / DBA
Primary Contact Name
First Name
Last Name
Primary Contact Email
example@example.com
Location
Location Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Internet Provider 1
Internet Provider
Account Number
Support Number
Please enter a valid phone number.
Format: (000) 000-0000.
Support Email
example@example.com
Bandwidth
Circuit ID
IP Address Range
Static IP
Yes
No
Subnet
Gateway
Primary DNS
Secondary DNS
Last 4 Digits of Modem
Internet Provider 2
Internet Provider
Account Number
Support Number
Please enter a valid phone number.
Format: (000) 000-0000.
Support Email
example@example.com
Bandwidth
Circuit ID
IP Address Range
Static IP
Yes
No
Subnet
Gateway
Primary DNS
Secondary DNS
Last 4 Digits of Modem
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Phone Provider
Phone Provider
Account Number
Support Number
Please enter a valid phone number.
Format: (000) 000-0000.
Support Email
example@example.com
Phone Type
Number of Phones
Phone Make and Model
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Office Survey
Number of Desktop Computers
Number of Laptop Computers
Total Printers at this Location
What Anti-Virus is being used?
What Spam Filter is being used?
What EMR do you use?
Copy Machine / Printer Repair / Fax Machine Vendor
Provide details for these resources / vendors
Network and Wireless
Firewall Model and Brand
Switch Model and Brand
Number of Wireless Access Points?
Are Access Points Password Protected?
Yes
No
Server
Number of Servers
Are Servers Virtualized?
Yes
No
Anti-Virus Used on Server?
Backup
Do you backup?
Yes
No
Backup Software Used?
Backup Stored?
Please Select
Off Premise
In Cloud
Both
Submit
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