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EMERGENCY MANAGEMENT PLAN SURVEY
Note: Fields marked with an "*" are required.
Date
* Facility Name:
* Facility Address:
* Facility City:
* Facility State:
* Facility Zip:

* Survey Respondent Name:
* Survey Respondent Phone:
Best Time to Contact: AM PM

Emergency Contact Information - Primary
Name:
Phone:
Alt. Phone:
Mobile Phone:
Email:

Emergency Contact Information - Secondary
Name:
Phone:
Alt. Phone:
Mobile Phone:
Email:

Imaging System Requesting Emergency Backup
CT Manufacturer: Model: Software Level:
MRI Manufacturer: Model: Software Level:
PET Manufacturer: Model: Software Level:
Nuc Med Manufacturer: Model: Software Level:

Facility Manager
Name:
Phone:

Do you currently have a prepared pad for mobile imaging system?
If yes, is the pad currently supplied with electrical power?
If yes, is the electrical power provided wired for emergency backup?
Does the facility currently have a portable backup power generator?
Any known special in or out transportation requirements/considerations for the mobile placement? (i.e. known special truck requirements, parking lot clearance, obstructions)
Will emergency service require the support of facility Information Systems? (i.e. connections to HIS, RIS, PACS, external laser imagers)
Does the facility currently have an Emergency Management Plan in place for Radiology/Diagnostic Imaging?
If yes, does it currently include a supplier of emergency mobile imaging equipment?
Does the facility currently have an Emergency Response Organization?
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