*
Required Field
Organization Name
*
City
*
State
*
Entity
*
Please Select
Non Profit
For Profit
Contact Name
*
Contact Title
*
Phone Number/Work
*
Format: (000) 000 - 0000.
Phone Number/Mobile
*
Format: (000) 000 - 0000.
Email
*
Do you have an existing mobile outreach program
*
Please Select
Yes
No
Describe services currently, or planning to be provided (i.e., primary care, preventive screenings, immunization, behavioral health, HIV/AIDS testing)
*
Describe population to be served (i.e., children, seniors, all ages, underserved, occupational, etc)
*
Where do you intend to serve
*
Please Select
Rural
Urban
Rural & Urban
Average miles/day mobile clinic will travel
*
Preference for type/style of vehicle
*
Motorcoach (Class A)
Bus (Class A)
Truck
Van (Class B orC) (Sprinter-type van)
Tow/Trailer (Cargo, ToyHauler, 5th Wheel)
No Preference
Engine (Fuel) Preference
*
Please Select
Gas
Diesel
No Preference
License Preferences
*
Please Select
CDL
Non CDL
No Preference
Preferred length of vehicle
*
Under 30'L Van (Class B or C)
30-35'L
36-40'L
40+L
No Preference
Will you require
*
Mammography Suite (1-screening room + 1-changing room)
1-Exam Room
2-Exam Rooms
Consult Room (behavioral health)
Multi-Purpose Room (testing, vaccination, school immunization, blood draw, etc.)
Lab Area
Intake/Reception Area
Waiting/Education Area
Bathroom
Wheelchair Lift
Wheelchair Ramp
Slide-Out
Are you planning to issue an RFP (request for proposal) to Vehicle Manufacturers
*
Yes
No
Already Issued
If yes, when?
By when do you want to acquire a vehicle
*
Estimated budget range
*
Status of funding
*
Please Select
Purchasing funds now available
Need assistance with financing
Applying for a grant
Are you applying for a grant?
*
Please Select
Yes
No
If applying for a grant, when is grant application due
-
Month
-
Day
Year
Date
If applying for a grant, who is the grantor
What is your anticipated grant amount range
When will grant be awarded
-
Month
-
Day
Year
Date
Additional Questions or Comments
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