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Attachment E: Local Mass Clinic Facility Worksheet <br />Local Strategic National Stockpile~Jass Clinic Facility Worksheet <br />±.l:,!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!-!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!l!!!!! _____ ....,_!!!!!!!l!!!!!!!!""""lil <br />County N ame: [ Public Health Region#: <br />Facility N ame: ! I Facility Code: <br />Facility Address: ! : Location Cross Street: <br />Facility Owner:. ! Facility Owner Phone:! <br />Primary Point of Contact I Alternate Point of Contact ! <br />N ame/Title: Name/Title:: ---------------+------------------------11 <br />DayPh~n_e_: ____________ __,. ________ D_a~y~P_h_o_n_e_: ___________ --1 <br />1 <br />Evening Phone: Evening Phone: --------------+-----------------------.. , <br />QCell Phone I O P-ager. 0 Ccll Ph one / O Pa.11er: ---------------+------'=------=-=-----------------11 <br />emai l address: email: <br />Facility capacity: I Sq. ft.: <br />_U !_Facility,:u-s ~ a ecmen.1 I~ la ce 0 Etectricity (a d~ua1 e o u.tkl.5 in clinic area) g Ba_cJ(\11?. J)O\\;tr source - <br />8 Adequat e road access 1 Wa t source: '.Cf -·AoA-rt'.l trcionis , i4 of stalls: .. <br />0 Sewer or 0' on-site sewage system <br />Htlicopta landing pad: [lon-site / 0 nearby D athletic fields · <br />0 , Alt. tTallSPonaLiorl' available: <br />N umb er of Puking St·i!.lh : I <br />, q : :f en_!:~g l..)ar?und fa clli.ty O around loadin_s area 0 Loading d ock <br />B , !c)_eph o111, a,·aila.bi!it y. P o~~l cruaHi ues : <br />f (add other items qfmlar,m h ,m,) <br />,._O j .(a_d_~ '?0 fJ ~.:_tems gf_imemt_!ie;:f) .. <br />I CL f'!~d oth111: ite1!1~efinterest lien;,, ~ -·· _ D I A d equate RV AC capad1 to mainr~in '1noiuial" temp in <br />·' , clini c area (as p er dn!_g ~t otagc guiddiu.es, 68-77 ":F) <br />0 I Plan customized to fit facility, following attachments <br />, · i (;Ol)).Jll-C l td <br />D Location map D site plan O clinic p lau D D ~eded e4uip, list <br />Facilit Plan Co oxd.in.ite d With : <br />.. <br />L ocal H ealth furisdi.aio11 i ·; ' Law Enforcement Agency: I <br />------------~ ;---------------111 <br />Emergency Management: 1 Fire Services: <br />Chief Electe~ Offi~~s: !~----------~· F:~ty ~~vner: j <br />56