EHPC EMS EEI COVID19 EHPC EMS EEI COVID19 This form is to be completed during a disaster or event Date*Please complete the date your agency completed this form. MM slash DD slash YYYY Time*Please complete the time your agency completed this form. Hours : Minutes AM PM AM/PM EMS agency name*Please list EMS agency name EMS level of service*Please select your EMS level of service for your agencyEMT-ParamedicEMT-IntermediateEMT-BasicName of person completing report*Please enter your name Phone of person completing report*Please add a phone number where you can be reached for questions.Email of person completing report*Please enter your email Daily average call volume*Please list average number of daily EMS callsPlease enter a number from 0 to 500.Average number of EMS transport units in service daily*Please list number of EMS transport units in service daily Please enter a number from 1 to 100.Average number of QRV units in service dailyPlease enter a number from 0 to 100.Please list average number of QRV units in service dailyStaffing shortage*Is your agency experiencing an increase shortage with staffing?YesNoStaffing comment boxPlease enter any comments here related to staffing Do you have any staff currently:*Please select appropriate checkboxes COVID positive Awaiting results On isolation N/A Number of staff with positive COVID*Please select number of staff positive with COVIDPlease enter a number from 0 to 50.Number of staff awaiting COVID results*Please list number of staff awaiting COVID resultsPlease enter a number from 0 to 100.Number of staff on isolation*Please list number of staff on isolation Please enter a number from 0 to 100.Ventilators on hand (if agency carries)*Please list number of ventilators on hand Please enter a number from 0 to 100.CPAP on hand (if agency carries)*Please list number of CPAP units on hand Please enter a number from 0 to 100.Anticipation of PPE needs*How soon do you anticipate PPE needs? N95s, surgical masks, gloves, gowns and eye protection Within 48 hours 48 hours to 1 week Over 1 week PPE needs*Please fill out any concerns related to PPE here. Make/Model/Type and description of concern. Also list resupply date if known. Any supply chain issues with Albuterol or steroids?*Please list if you are having any issues with getting albuterol or steroids YesNoPlease describe supply chain issues*Please describe what supply chain issues you are having with Albuterol and/or steroids. List expected resupply date if able Does your agency have a PPE reuse policy?*Please select if your agency has a reuse procedure/policyYesNoPlease describe reuse procedure*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). Surge in flu like calls*Has your agency seen a surge in flu like calls for service? (Other than normal seasonal volume?)YesNoNot sureNurse triage line available in your jurisdiction/county?*Do you know of a nurse triage line for COVID19 in your jurisdiction/county?YesNoGeneral commentsPlease list any concerns or comments here
