EM Resource Restructuring Initiative
In an effort to revitalize and update our EM Resource instance, and to comply with the upcoming mandated drill requirements, we are asking all facilities to take the time to update their current user and EMC lists by filling out the information below.
Please complete and submit this form no later than November 30, 2024
Facility Name:
*
Facility Type:
*
Please Select
Aeromedical
Assisted Living
EMS (EMS Agencies - Fire Department EMS - Private EMS)
Free-Standing ED
ICF/IID
Level I Trauma
Level II Trauma
Level III Trauma
Level IV Trauma
Non-Designated Hospital
Nursing Home
Psychiatric (Psychiatric Facilities / State Hospitals)
Specialty (Skilled Nursing, Long-Term Acute Care)
Type Must Be Selected. If facility is currently listed as "Not Available" in EM Resource, please select "Non-Designated".
Facility Physical Address:
*
Street Address (No PO), City, Zip Code
Facility Main Phone Number
*
Please enter a valid phone number.
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EM Resource Restructuring Initiative
Facility Contact Information - Emergency Management Coordinator
The facility EMC will be the second point of contact in an emergency if the house supervisor cannot be reached.
Facility EMC Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number:
*
Please enter a valid phone number.
Are you the designated EMC for multiple facilities?
*
Yes
No
If "yes", please list each facility below, along with physical street address, city, zip code:
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EM Resource Restructuring Initiative
Facility contact information - House Supervisor
Please list all house supervisors. Please list the HS shared phone number where indicated. If no shared number, please list the phone number associated with each HS that may be contacted during an emergency. **NOTE** Only the first HS information is required to submit form, however, all HS must be listed by completing the information for each HS in your facility.
1. Facility HS Name:
*
First Name
Last Name
Email
*
example@example.com
Phone Number:
*
This should be the phone number used by all shift supervisors that can be reached 24/7 in an emergency.
This Phone is:
*
Shared HS Phone
HS Personal Phone
If this is a personal phone, what shift does the HS work?
*
Day Shift HS
Night Shift HS
What facility does this HS work at?
(if EMC has multiple facilities listed)
2. Facility HS Name:
First Name
Last Name
Email
example@example.com
Phone Number:
This should be the phone number used by all shift supervisors that can be reached 24/7 in an emergency.
This Phone is:
Shared HS Phone
HS Personal Phone
If this is a personal phone, what shift does the HS work?
Day Shift HS
Night Shift HS
What facility does this HS work at?
(if EMC has multiple facilities listed)
3. Facility HS Name:
First Name
Last Name
Email
example@example.com
Phone Number:
This should be the phone number used by all shift supervisors that can be reached 24/7 in an emergency.
This Phone is:
Shared HS Phone
HS Personal Phone
If this is a personal phone, what shift does the HS work?
Day Shift HS
Night Shift HS
What facility does this HS work at?
(if EMC has multiple facilities listed)
4. Facility HS Name:
First Name
Last Name
Email
example@example.com
Phone Number:
This should be the phone number used by all shift supervisors that can be reached 24/7 in an emergency.
This Phone is:
Shared HS Phone
HS Personal Phone
If this is a personal phone, what shift does the HS work?
Day Shift HS
Night Shift HS
What facility does this HS work at?
(if EMC has multiple facilities listed)
If additional space is needed for HS information, please email aaron@rac-g.org with the above data completed for each.
Submit
Should be Empty: