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
Availability of Essential Equipment (check all that apply):
Other
How would you rate your facility's current infection control protocols?
Emergency Preparedness: Does your facility have up-to-date emergency response plans?
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:

Select theme:

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