Laserfiche WebLink
Attachment E: Local Mass Clinic Facility Worksheet <br />i I Loci SCTaleg1 c . ational co ckpiJe . Jus Clinic Facility \, o rlubeet <br />CountyNarne: i Public Health Region #: <br />Facility Narne : Facility Code: <br />Facility Address : ! Location Cro ss Street : <br />Facility Owner : Facility Owner Phone: <br />Primary Point of C ontact Alternate Point of C ontact <br />N arne/Title : Namc .. Title : <br />Da Phone : Day Phone: <br />I <br />Evening Phone: Evening Phone: <br />DCell Phone i DPager DCe1l Phone,' DPager: <br />email address: emai l: <br />Facility capacity: I Sq . ft . Number of P asf<jllg St alls , <br />B F acili~ >' use asrceme.nt ill place B Fencing Daroulld facili t), Daround loading area <br />;Electricit~' (adcquateoudct s ill clini c area) Loading dock <br />'0 Backup power source 0 TelePhone a 'lll1ability, # of cxtemallines: <br />'0 Adequa te road access 0 (erdd ollter i l irIS ofMterlJ~( ltel:fJ) <br />0 WlI,t.er source: 0 (add othw items qjil!!erf!Sl hfilrll) <br />q ADA Icsrrooms, it of sra1ls.: 0 iadd olitel' !!~I S olfnt est heny <br />o S ewer or 0 ou.-site sewage s~'$tem 0 Adl!quate R AC apadty to maintain "normal" temp in <br />clinic area (as per drugsrorage guidelines. 68 -77°f) <br />0 Heli cop tt!l' Lmding-pad : 0 ou.-site " 0 nearby 0 Plan customized to fit facility, follm.ving attaclunents <br />athletic fields complcud <br />0 All. rrnllsponation.a ,,-ailablc.: [] Location.map 0 she plan-O c.1lnic plan 0 n"CCded equip list ' <br />Facilit y Plan Coordinated With _ <br />Local Health Juri sdiction: Law Enforcement Agency: <br />. <br />Emergency Management : Fire S ~ices : <br />I <br />Chief Elected Officials : Facility Owner: <br />56