Healthcare Readiness Assessment Form

Healthcare Readiness Assessment Form
Evaluate your facility's preparedness across key healthcare domains.
Facility Information
Please provide basic details about your healthcare facility.
Facility Name*
Facility Address*
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Person Full Name*
First NameLast Name
Contact Email Address*
example@example.com
Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Type of Facility*
Staffing Levels: Please indicate the current staffing status for each role.*
Rows Fully Staffed Partially Staffed Significantly Understaffed Not Applicable
Physicians
Nurses
Support Staff
Emergency Personnel
VentilatorsPersonal Protective Equipment (PPE)DefibrillatorsOxygen SupplyIsolation RoomsOther
How would you rate your facility's current infection control protocols?*
Yes, fully up-to-datePartially up-to-dateNo, needs updating
Staff Training: Please indicate the extent of recent staff training in the following areas.*
Rows Completed in Last 6 Months Completed in Last Year Not Completed
Infection Control
Emergency Procedures
Use of PPE
Patient Triage
On a scale of 1 to 10, how confident are you in your facility's ability to respond to a sudden influx of patients?*

1
2
3
4
5
6
7
8
9
10
1 is Not Confident, 10 is Extremely Confident
Additional Comments or Concerns
Should be Empty:

Rows	Fully Staffed	Partially Staffed	Significantly Understaffed	Not Applicable
Physicians
Nurses
Support Staff
Emergency Personnel