Hospital Evacuation Liaison Program

Proposal Request

HELP program administrators will be happy to speak with you personally about your specific needs for disaster planning assistance. To expedite that process, we can prepare a preliminary proposal for you based on your responses to the following questions.

How many facilities would be included under the proposal? (use comment section if necessary)

What are the bed counts at each facility?

What are the approximate numbers of total patients at each facility that are:

Ambulatory
Wheelchair
Stretcher
ICU
Vent
Pediatric
Neonatal
Other (please list with approximate counts):

What types of services might you require from our program?

Evacuation Pre-Planning
Communications Coordination
Grant Writing Support
Logistical Support
Identifying & Contracting with Ground & Air Medical Transports
Additional Medical Personnel
Insurance Assistance
Training/Drills
Identification of Receiving Hospitals

Name:
*

Title:
*

Facility:
*

Mailing Address:
*

City:
*

State:
*

Zip:
*

Phone:
*

Fax:
*

Email
*

Comments:

* Required

For more information contact:
800/633-5384; info@hospitalevac.org