SETRAC Healthcare Organization Engagement Visit

SETRAC Healthcare Organization Engagement Visit

Please complete the below form if you would like to schedule a visit for the SETRAC Special Populations team to come out to the facility, agency or clinic for an overview of your preparedness and training programs, as well as ensuring the organization is taking advantage of available coalition resources. Among other things, best practices will be shared, communicating with the CMOC and resource availability through the latter during disasters, ensuring we are all on the same page.
Facility/Agency/Clinic Name*
Name of Person Completing this form*

First NameLast Name
Direct Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

City

CountyState

Zip Code
Does the Facility have a current SETRAC Agreement completed and included in the MOU section of the EOP (Emergency Plan)*

YesNoNot Sure
If you answered "No" or "Not Sure" to the questions above, please click on the folowng link to access the SETRAC Coalition Membership Agreement document. You can complete digitally or print and complete. Completing the agreement will make your facility/agency a member of the healthcare coalition, and will allow you to fully participate in meetings, drills, exercises, training, planning and technical assistance. The agreement and related participation can be also used towards your CMS compliance goals by adding a copy of it in your EOP agreements section, as a member of an active regional healthcare coalition. Agreement will end June 30, 2025.

https://forms.setrac.org/fidel.calvillo/healthcare-entity-participation2025
Appointment Date & Time*
Should be Empty: