HEF

HOSPICE Resource and Support Form

Agency Name(Required)

Evaluator Name(Required)

First Last

Evaluator Email(Required)

Create a list of medical supplies you have on hand that were available to share with local hospitals for treatment of flood victims.(Required)

Include the time you reported your medical supply list information.(Required)

How many staff members did you have available to send to local hospitals?(Required)

How many available in-patient beds (with staff to support) did you have available to support the response? Include the time you reported this information!(Required)

Include the time you reported this information!(Required)