Company Name

Street Address

City

Zip Code

Phone Number

E-mail

Website

Total no. licensed beds

Total no. in-patient admissions last fiscal year

Total no. out-patient visits last fiscal year

Total no. full-time and part-time physicians

Total no. full-time and part-time RNs

Total no. full-time and part-time hospital staff

Other hospital-related facilities in area (please list name and city)

Three areas of specialty

Parent company

Administrator

Year established

Annual revenue

Survey completed by