DAS Questionnaire - Communications Tower Group

Name*

First Last

Title*

Contact Number*

Email*

Preferred Method of Contact

Facility Name*

Facility Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Facility Square Footage*

Number of Beds*

Annual Inpatient*

Annual Outpatient*

Number of Staff*

Annual Occupancy (patients, staff, visitors)*