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Attachment D: Local Mass Clinic Facility Worksheet <br />+ Local Strategic National Stockpile8lass Clinic Facility Worksheet <br />" <br />County Namcc Public Health R~on #: <br />Facility Name: Facility Code: <br />F ac.ility Address: Location Cross Street : <br />Facility Owner: Facility Owner Phone: <br />Primary Point of Contact Alternate Point of Contact <br />Name/Title: Nametritle: : <br />Day Phone: Day Phone: <br />Ev~gPhone : Evening Phone: <br />DCell Phone ! DPager: DeeR Phone ': OPager: <br />email address : email: <br />Facility capacity: I SqfL Number of Parking Stalls : , <br />LJ Facility use ~reeIllent in place _ 0 Fencing Qarollnd facility Darol,lJld loading ~ <br />0 Electricity (adequate outlers in clinic area) 0 loading dock <br />0 Backul? powet_ ~our~ 0 Telephone availability, # of e."tternallin:es: <br />0 Adequace road access 0 (f1II.tj odwr items o!iit1in-erl ,,~~) <br />0 Walet source: 0 (tufd otJuu items ofl1lterQs[ hm-ej <br />0 ADArestrooms, # ofsta1ls : c:r (aJd othiu if.ems ofi itr«YillT Iwre) <br />D Sewer or 0 on-site sewage syst em 0 Adequate HVAC capacity to malnuin .J.normaT' temp in <br />clinic areafu tItr drugstora .~ guidelines; 6S-71 "f) <br />0 Helicopter l~ding pad: [) on-site ,' tl nearby 0 Plan customized to fit faCluty. following actachments <br />athletic fields comp le[~ <br />0 AlL ~ation available: o Location map 0 site plan 0 clinic plan 0 needed equip list <br />Facili~ ~ Soordin~t~ \Vith: ----. --~.- <br />Local Hwtl1 Iurisdiction: Law Enforcement Agency: <br />Emergency lVIanagement : Frre Services : <br />Chief Elected Officials: F aci1ity Owner: <br />57