Basic Health Care Facility Information Form

The requested information below will be sent to the Office of Emergency Management. Update and submit this sheet annually.

Facility Name

Phone

Fax

Faculty Address

Address

City

Zip

Primary 24-Hour Point of Contact

Contact Name

Contact Address

Contact City

Contact Zip

Contact Email

Contact Work Phone

Contact Home Phone

Contact Cell Phone

Alternate 24-Hour Point of Contact

Alternate Name

Alternate Address

Alternate City

Alternate Zip

Alternate Email

Alternate Work Phone

Alternate Home Phone

Alternate Cell Phone

Number of Beds at This Facility

Number of Full Time Employees

Number of Part Time Employees

Number of Vehicles Available for Emergency Evacuation

Name Of Your Facility’s Paired Facility

This Facility Has an Emergency Generator

Yes

No

Available for Emergency Training and Exercises

Yes

No

A Member of the Tennessee Highland Rim Healthcare Coalition

Yes

No

By checking this box and typing my name below, I am electronically signing my application. I understand that my electronic signature has the same legal effect as my written signature.

First Name

Middle Initial

Last Name

Suffix