Emergency Management Planning Survey

Emergency Contact Information -   Primary                                   Secondary

Imaging System Requesting Emergency Backup

Facility Manager

Do you currently have a prepared pad for mobile imaging system?
Yes No

If yes, is the pad currently supplied with electrical power?
Yes No

If yes, is the electrical power provided wired for emergency backup?
Yes No

Does the facility currently have a portable backup power generator?
Yes No

Any known special in or out transportation requirements/considerations for the mobile placement? (i.e. known special truck requirements, parking lot clearance, obstructions)
Yes No

Will emergency service require the support of facility Information Systems? (i.e. connections to HIS, RIS, PACS, external laser imagers)
Yes No

Does the facility currently have an Emergency Management Plan in place for Radiology/Diagnostic Imaging?
Yes No

If yes, does it currently include a supplier of emergency mobile imaging equipment?
Yes No

Does the facility currently have an Emergency Response Organization?
Yes No

Comments: