EMERGENCY PREP CHECK

This form is in a (Yes or No) format, if you wish to leave any comments or unsure how to answer a question, please leave a response in the "Notes/Comments" section below or reach out to an administrator. Thank you.

First Name

Last Name

Today's Date

Location

Role in Company

Please fill out the following section if you are FIELD STAFF. (Office Staff mark as "No")

What's your tablet ID? *If office staff leave blank*

Do you have Microsoft Teams set up on your tablet?

Do you have Microsoft Outlook (EMAILS) set up on your tablet?

Please fill out the following section if you are OFFICE/REMOTE STAFF. (Field staff mark as "No.")

Do you have a laptop assigned? (Y/N)

Do you have Vonage on your personal phone? (Y/N)

Do you have Microsoft Teams on your personal phone? (Y/N)

Do you have Microsoft Outlook (EMAILS) on your personal phone? (Y/N)

Notes/Comments

I Accept that all the information above is accurate to the best of my knowledge and will be used by Superior

Please Note: By completing this form, you agree to release your information to Superior Hospice & Superior Home Health. Your privacy is very important to us. All information submitted through this form is secured and viewed only by our staff. Read our privacy policy for more info.