Crucible AI — Client Intake Survey

Organization Information

Step 1 of 7

Organization Name *

Legal Entity Name (if different)

Primary Contact Name *

Primary Contact Email *

Primary Contact Phone

Mailing Address

Website

Industry & Regulatory Profile

Step 2 of 7

Primary Industry *

Secondary Industries (if applicable)

State(s) of Operation *

Number of Locations/Facilities *

Approximate Number of Employees

Federal Regulators

CMS OSHA EPA DEA OIG HUD DOJ SAMHSA FDA FMCSA DOL HRSA

State Regulators

Accreditation Bodies

Joint Commission CARF NCQA ACHC CHAP None

Current Compliance Operations

Step 3 of 7

Do you have dedicated compliance staff?

Yes No

How many compliance staff?

Their roles/titles

How do you currently track regulatory changes?

How do you currently manage compliance documentation?

Any regulatory citations or violations in the past 3 years?

Yes No

Brief description

Biggest compliance pain point

Documents & Procedures

Step 4 of 7

Approximate number of compliance documents maintained

Primary document format

Paper PDF Word/DOCX EHR System Spreadsheets Scanned Images

Technology Environment

Step 5 of 7

Do you have a dedicated IT person or department?

Yes No

Current EHR/EMR System (if healthcare)

Current document management system

Do you use PointClickCare?

Yes No N/A

Internet connection type and speed

Server room or dedicated IT closet available?

Yes No

Comfortable with on-premise hardware?

Crucible runs on a small mini-PC on your network. Your data never leaves your building.

Yes No Not Sure

Deployment Preferences

Step 6 of 7

Preferred deployment timeline

As soon as possible Within 30 days Planning phase — no rush

Number of users who will access Crucible

Departments that need access

Compliance Administration Clinical HR Finance Operations IT

Do you handle Protected Health Information (PHI)?

Yes No

Specific data sovereignty requirements?

Budget & Decision Making

Step 7 of 7

Who is the decision maker for this purchase?

Is there an approval process or board vote required?

Yes No

Do you have budget allocated for compliance technology?

Yes No Exploring

How did you hear about Crucible?

Crucible AI — Client Intake Survey

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Survey Submitted

Organization Information

Industry & Regulatory Profile

Current Compliance Operations

Documents & Procedures

Technology Environment

Deployment Preferences

Budget & Decision Making