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Please read bullets below before beginning survey.
  • Your responses to this questionnaire provides ZDR3 the basic information we need from each ZDR3 Network facility member, including how to best communicate with you if you can help render, or need to receive assistance, in the event of a disaster.
  • If you own facilities in multiple locations, each one will need to have its own Memorandum of Understanding (MOU), and individual responses to this questionnaire, as different locations may have different points of contact and demographic information.
  • Any information submitted will only be accessible by the core ZDR3 communication and command staff. It will not be made public or disseminated.
  • If you have any questions about this questionnaire, please contact us at admin@zdr3.org. We can respond via email or, if you prefer, you can ask to schedule a call.
  • ZDR3 uses Constant Contact email automation services as a means of communicating with our network members. Execution of the MOU automatically consents to enrolling your designated points of contact into Constant Contact email subscription.

Thank you for helping us gather the information that will help us more effectively and efficiently deploy resources to our colleagues in need!

Facility Information
* Facility Name
0/250
* Facility Address (physical location, including county)
0/250
Mailing Address (if different from physical)
0/250
* Time Zone
* Main Business Type
* Secondary Business Type (select all that apply)
* Is public visitation allowed?
* Governance/Ownership (select all that apply)
* USDA Licensed
USDA License #
0/50
* Facility Accreditation(s) (select all that apply)
* Facility Certification(s) (select all that apply)
* Facility Membership(s) (select all that apply)
* Regional Industry Association Membership (select all that apply)

Primary Facility Point of Contact (Owner, Director, Manager, etc.)
* Name
0/250
* Title
0/250
* Email Address
0/250
* Phone Number (mobile)
0/250
* Phone Number (alternate)
0/250

Secondary Facility Point of Contact

Please indicate who to contact if the primary POC cannot be reached.
* Name
0/250
* Title
0/250
* Email Address
0/250
* Phone Number (mobile)
0/250
* Phone Number (alternate)
0/250

Safety and/or Security POC
Would you like to designate a staff member in charge of safety and/or security?
Name
0/250
Title
0/250
Email Address
0/250
Phone Number (mobile)
0/250
Phone Number (alternate)
0/250

Communications and Public Relations

ZDR3 includes interested program participants in our promotional and fundraising work.
* Do you want your involvement with the ZDR3 network to be recognized on the ZDR3 website and social media? We will work with your designated communications representative to ensure accurate and appropriate messaging.
* Would you like to include contact information for your communications and/or PR staff?
Name
0/250
Title
0/250
Email Address
0/250
Phone Number (mobile)
0/250
Phone Number (alternate)
0/250
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