Healthcare Forms Select a form Healthcare - Background Form Healthcare - On-site Form Healthcare - Post Visit Form Healthcare - Background Form Healthcare Background Form1Your Information2Company Information3Company Contacts4Parent Company Information5Status6Local Employment7Facility8Utility Services9Community ServicesYour InformationPerson filling out form*Phone*DateCompany InformationCompany Name*Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Sectors*Advanced ManufacturingAeronautics and DefenseAgricultureBuilding & ConstructionBusiness ServiceCommunicationsConsumer Goods ProducerConsumer ServicesConvention/TourismCreative ArtsDiversifiedDurable Goods ProducerEnergy & Energy UtilitiesFilm and Movie ProductionFinance, Insurance, & Real Estate (F.I.R.E.)ForestryGovernmentHealth Care & PharmaceuticalsHigh End Business ServiceIndustrial GoodsMineralNon-ProfitRetail Related OperationsTechnology/InformationTelecommunicationsUtilitiesDownload the printable PDF for sector descriptions DownloadNAICS*561 - Administrative and Support Services3364 - Aerospace Manufacturing115 - Agricultural & Forestry - Support Activity112 - Animal Production315 - Apparel Manufacturing3361 - Automotive Manufacturing312 - Beverage and Tobacco515 - Broadcasting (except internet)233 - Building, Developing, and General Contracting325 - Chemical Manufacturing/Biopharmaceuticals334 - Computer and Electronic Product Manufacturing234 - Construction - Heavy238 - Contractors - Special Trade522 - Credit Intermediation and Related Activities111 - Crop Production518 - Data Processing, Hosting and Related Services611 - Educational Services335 - Electrical Equipment, Appliance, and Component Manufacturing332 - Fabricated Metal Product Manufacturing311 - Food Manufacturing113 - Forestry and Logging525 - Funds, Trusts, and Other Financial Vehicles337 - Furniture and Related Product Manufacturing622 - Hospitals524 - Insurance Carriers and Related Activities316 - Leather and Allied Product Manufacturing333 - Machinery Manufacturing551 - Management of Companies and Enterprises213 - Mining - Support Activity212 - Mining (except Oil and Gas)339 - Miscellaneous Manufacturing512 - Motion Picture & Sound Recording327 - Nonmetallic Mineral Product Manufacturing81 - Non-Profits; Religious, Grantmaking, Civic, Professional, and Similar Organizations; Other Services211 - Oil and Gas Extraction519 - Other Information Services322 - Paper Manufacturing324 - Petroleum and Coal Products Manufacturing326 - Plastics and Rubber Products Manufacturing3261 - Plastics Manufacturing331 - Primary Metal Manufacturing323 - Printing and Related Support Activities541 - Professional (Business), Scientific, & Technical Services92 - Public Administration511 - Publishing Industries (except Internet)523 - Securities, Commodity Contracts, and other Financial Investments and Related Activities711 - Sports Advisory Service517 - Telecommunications313 - Textile Mills314 - Textile Product Mills48 - Transportation336 - Transportation Equipment Manufacturing221 - Utilities493 - Warehousing & Storage562 - Waste Management & Remediation Services321 - Wood Product ManufacturingDownload the printable PDF for NAICS descriptions DownloadWebsite Company Email Previous Company Name (if applicable)Electric UtilityNatural Gas UtilityCompany ContactsContact #1Name First Middle Last TitleCell PhoneWork PhoneEmail Contact #2Name First Middle Last TitleCell PhoneWork PhoneEmail Parent Company Information (if applicable)Parent NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneWebsite Top Executive Name First Last Executive TitleStatusMember/Investor* Yes NoBeginning of fiscal yearJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberType of ownership (check all that apply)* Public Family Minority-owned State Government Employee-owned Veteran-owned Native American Federal Government Private Woman-owned Non-profit Foreign Owned6-Digit NAICS code(s) Primary product(s)Local EmploymentFull NameShifts per dayPart timeDays per weekContract/LeasePeak employment season Spring Summer Fall Winter NoneNumber of jobs added or lost in the past three yearsUnion at company* Yes NoPrimary unionContract expiration dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employment by position - numberManagementTechnicalSales/MarketingAdministrative/OfficeProductionTotal gross annual payrollFacilityRoom for expansion* Yes NoFacility ownership* Own LeaseLease expiration dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Property owner informationBuilding Size (sq. ft.)Number of buildingsAcreageType of facility (check all that apply) Office operation Headquarters Distribution/Warehouse Branch Plant Division R&D ManufacturingOther facility with similar products* Yes NoLocationsAge of main building < 10 years 10-25 years > 25 yearsCondition of building Excellent Good Average Fair PoorFacility appeal Excellent Good Average Fair PoorFacility functionality Excellent Good Average Fair PoorPast expansion/reduction Expansion ReductionPast expansion dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Past reduction dateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Expansion Sq. Ft.Reduction Sq. Ft.Expansion InvestmentReduction InvestmentNumber of Expansion JobsNumber of Reduction JobsExpansion purposeReduction purposeUtility ServicesHow is the consumption of the following utilities changing?IncreasingStableDecreasingWaterSewerNatural GasElectricTelecom (voice)Cellular serviceInternet accessInternet speedPlease rate your satisfaction with your utility providers1234567WaterSewerNatural GasElectricTelecom (voice)Cellular serviceInternet accessInternet speedPlease comment on any utility services with low satisfaction (3 or lower) or high (5 or above)UtilityComment Utility NotesCommunity ServicesPlease rate the quality of the following services provided by the community on a scale of 1 to 7, 7 being high.1234567Police protectionFire protectionAmbulance paramedic serviceHealth care servicesChild care servicesSchool (K-12)Tech collegeCommunity collegeCollege(s) and university(ies)Public transportationTraffic controlStreets and roads (local)Highways (State & Federal)Airline passenger serviceAir cargo serviceTruckingProperty tax assessment (fair & equitable)Zoning changes and building permitsRegulatory enforcement (fair & equitable)Community planningCommunity services (not otherwise listed)County services (not otherwise listed)Chamber of Commerce or business associationEconomic development organizationWorkforce servicesPlease comment on any services with low satisfaction (3 or lower) or high (5 or above)ServiceComment Services Notes Healthcare - On-site Form Healthcare On-Site FormStep 1 of 714%CompanyCompany NameAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lead Interviewer First Last Contact Name First Last Assisted By First Last Other ParticipantsFirst NameLast Name AppointmentProducts/Services1. What is your company’s greatest achievement in the last three (3) years?2. Do you serve any special market niches or produce any customized products/services from this location? Yes NoPlease explain:3. What type of businesses/products are your customers looking for that they are not finding in this community?4. Does your company have any difficulty securing needed business services in the area? Yes NoWhat services?5.1 Have there been any changes in distributor/supplier relationships that have negatively impacted your business in the last two (2) years? Yes NoComments?5.2 Are any distributor/supplier changes anticipated? Yes NoComments?6.1 Percentage of sales outside local market/region: Under 5% 5%-20% 21%-35% 36%-50% Greater than 50%6.2 Past year, sales outside local market Increasing Stable Decreasing7. What is the range of total company sales? Below $100,00 $100,000 - $250,000 $250,001 - $500,000 $500,001 - $750,000 $750,001 - $1 million $1 million - $2 million $2 million - $5 million More than $5 million8. Are total sales for your operations: Increasing Stable DecreasingWhat is the primary influence?9. Does the company plan to expand or renovate this facility in the next three years? Expand Renovate NoneEstimated InvestmentEstimated percentage-aestheticEstimated percentage-equipment/technologyEstimated percentage-structuralEstimated facility size increase (if any)Estimated number of jobs added or lost (-)Full-Time EmployeesApproximate date of improvementsMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192010. Do you plan to open an additional location(s) in the next two (2) years? Yes NoComments?Marketing11. Is the company’s advertising/promotion budget Increasing Stable Decreasing None12. Does your company invest time/money in a cooperative marketing effort (advertising, events, promotions, etc.) with other area businesses? Yes NoMarketing NotesManagement13. In the past 18 months has the company’s ownership or senior management changed or are changes expected? Ownership/senior management has changed Planned to change ownership/senior management Local manager has changed Planned to change local manager No changesComments?14. Is the owner or one of the owners involved in the day-to-day operations of the business? Yes NoManagement NotesWorkforce15. Survey1 - Low / 7 - High1234567How do you rate the availability of workers in this area:How do you rate the quality of workforce in this area:How do you rate the stability of workforce in this area:As compared to other company facilities, how would you rate productivity in this facility:16. Are projected employment needs for this facility:IncreasingStableDecreasing17. Is the number of unfilled positions:IncreasingStableDecreasing17a. Approximate number of unfilled positions today:17b. Current full-time employment17c. Current part-time employment17d. Current leased employment18. Does the business provide any of the following benefits? Health Insurance Pension 401k/Profit Sharing NoneBenefits are offered to: Full-time Part-time BothWhat percentage of health benefit are covered by the employer?Individual %Family %19. Is company investment in employee training:IncreasingStableDecreasingNoneWorkforce NotesTechnology20. Is the community’s technology infrastructure adequate for your company’s growth plan? Yes NoComments:Technology NotesCommunity Business Climate21. What are the community’s strengths as a place to do business?22. Are there any barriers to growth in this community Yes NoWhat are the barriers to growth?23. Have there been any changes in the community or neighborhood impacting your business in the last two (2) years (demographic, physical, competition)? Yes NoComments24. Do you anticipate any community or neighborhood changes? Yes NoComments25. Do you anticipate any federal, state, or local legislation changes that will adversely affect your business in the next five years: Yes NoWhat changes? How will they affect your company?26. Has your attitude toward doing business in community changed during the last two (2) years? Yes NoHow has your attitude changed?27. Does your company have any difficulty securing needed business services (ie, partners, suppliers, technology) in the area? Yes NoWhat services?Community Notes Healthcare - Post Visit Form Healthcare Post Visit FormStep 1 of 333%CompanyAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of VisitMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lead InterviewerContact NameAssisted byAppointmentOther ParticipantsCompany Assessment1. Do you have any reason to believe this company’s role in the community could be changing? Yes NoComments2. Is there any reason to believe this company is at risk of leaving the community? Yes NoCommentsProduct NotesExecutive Assessment3. Is the company or its executives undergoing any form of stress that could be of concern for the company’s stability in the community? Yes NoComments4. Rank the executive’s support for the community as a place to do business?1 (Low)234567 (High)5. Rank the executive value for working with the economic development program in some capacity?1 (Low)234567 (High)Interviewer Notes
