Hospital Survey (D3) Name* First Last Email* Phone*Hospital Name* Street Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name your evaluator. What type of exercise does your facility plan to have?*Select OneFull ScaleFunctionalTabletopNoneOther than evaluating Incident Command, check all other capabilities your facility needs to exercise. Patient Surge Decon Evacuation Workplace Violence Other What other capabilities does your facility need to exercise? Number of Licensed beds at your facility:* Number of Staffed beds at your facility:* Average Daily Census of your facility* How many patients does your facility require to affectly exceed your patient surge capability?* Of the total patient numbers given, how many should be triaged red?* Of the total patient numbers given, how many should be triaged yellow?* Of the total patient numbers given, how many should be triaged green?* Any other comments or considerations for the Exercise Planning Committee?How did you hear about VPC? Referral from work or colleague Internet search (e.g., Google) Social media Printed story or ad
