FSED/Urgent Care Status

FSED/Urgent Care Status
Name of Agency/Facility *
Address *

Street Address

Street Address Line 2

City State

Zip Code
County *
Point of Contact Name *

First Name Last Name
Point of Contact 24/7 Phone Number *

Area Code Phone Number
Point of Contact Email *
example@example.com
Agency/Facility Type *

FSED Hospital Affiliated FSED Non-hospital Affiliated Urgent Care
No. of Average patients/day *
No. of Staff on Duty Daily *
Are You Experiencing Staff Absenteeism? *

Yes No

If yes, reason for absences: Please put the number of each absence in the appropriate category. *

Quantity

Self illness

Mandatory quarantine

Family illness

School/daycare closure

Thank you. If you are in need of additional PPE, please complete the request form by clicking this link: PPE Request
Should be Empty: