HEF

HOSPICE Resource and Support Form

Agency Name(Required)

Evaluator Name(Required)

First Last

Evaluator Email(Required)

List the type of supplies you have to support the Triage and Treat Centers in Lewis, Nicholas and Braxton Counties.(Required)

How many staff members did you have available to send to the scene?(Required)

How many available in-patient beds (with staff to support) did you have available to support the response?(Required)