Please complete the date your agency completed this form.
MM slash DD slash YYYY
Please complete the time your agency completed this form.
Please list EMS agency name
Please select your EMS level of service for your agency
Please enter your name
Please add a phone number where you can be reached for questions.
Please enter your email
Please list average number of daily EMS calls
Please list number of EMS transport units in service daily
Please list average number of QRV units in service daily
Is your agency experiencing an increase shortage with staffing?
Please enter any comments here related to staffing
Please select appropriate checkboxes
Please select number of staff positive with COVID
Please list number of staff awaiting COVID results
Please list number of staff on isolation
Please list number of ventilators on hand
Please list number of CPAP units on hand
How soon do you anticipate PPE needs? N95s, surgical masks, gloves, gowns and eye protection
Please fill out any concerns related to PPE here. Make/Model/Type and description of concern. Also list resupply date if known.
Please list if you are having any issues with getting albuterol or steroids
Please describe what supply chain issues you are having with Albuterol and/or steroids. List expected resupply date if able
Please select if your agency has a reuse procedure/policy
Please describe your reuse procedure. We are mainly looking for data on N95, faceshield and eye protection. What is the collection plan? (End of shift, end of call etc).
Has your agency seen a surge in flu like calls for service? (Other than normal seasonal volume?)
Do you know of a nurse triage line for COVID19 in your jurisdiction/county?
Please list any concerns or comments here