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| Facility Type:* |
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| If part of a group, number of hospitals in group: |
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| Are your IT services centrally managed? |
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| Do you have any dial up connections to your network? |
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| How do you deploy software? |
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| At what stage are you in establishing your incident management needs? |
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| What do you hope to achieve with an incident management system? |
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| Describe your current incident monitoring system: |
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| Which of these specialty services does your facility provide? |
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| When do you expect to purchase? |
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| What is your role?* |
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If other: |
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