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COVERED Need and Capacity Assessment

Your information

1. Your name

*This question is required.

2. Your email

*This question is required. This question requires a valid email address.

3. Your organization name *This question is required.

8. Please list your priorities and existing capabilities *This question is required.

Space Cell	High unmet priority	Low unmet priority	Existing capability
Digital screener with appointments	Digital screener with appointments: High unmet priority	Digital screener with appointments: Low unmet priority	Digital screener with appointments: Existing capability
Triage and education bot for website	Triage and education bot for website: High unmet priority	Triage and education bot for website: Low unmet priority	Triage and education bot for website: Existing capability
Virtual Waiting Room and Zero Contact Check-in	Virtual Waiting Room and Zero Contact Check-in: High unmet priority	Virtual Waiting Room and Zero Contact Check-in: Low unmet priority	Virtual Waiting Room and Zero Contact Check-in: Existing capability
Telehealth and video visits	Telehealth and video visits: High unmet priority	Telehealth and video visits: Low unmet priority	Telehealth and video visits: Existing capability
Home surveillance of at risk population	Home surveillance of at risk population: High unmet priority	Home surveillance of at risk population: Low unmet priority	Home surveillance of at risk population: Existing capability
Employee health and wellness	Employee health and wellness: High unmet priority	Employee health and wellness: Low unmet priority	Employee health and wellness: Existing capability
Pre and post Hospital and ED care automation	Pre and post Hospital and ED care automation: High unmet priority	Pre and post Hospital and ED care automation: Low unmet priority	Pre and post Hospital and ED care automation: Existing capability
Device based remote patient monitoring including pulse oximeter	Device based remote patient monitoring including pulse oximeter: High unmet priority	Device based remote patient monitoring including pulse oximeter: Low unmet priority	Device based remote patient monitoring including pulse oximeter: Existing capability
Enter another option	Other: High unmet priority	Other: Low unmet priority	Other: Existing capability

9. In what way, we can help you the most? (please describe in 1-2 sentences)

10. Name your EHR/ care management system

11. How did you hear about us?

Please enter an 'other' value for this selection.