EHPC EMS EEI COVID19

Date*

Please complete the date your agency completed this form.

Time*

Please complete the time your agency completed this form.

:

EMS agency name*

Please list EMS agency name

EMS level of service*

Please select your EMS level of service for your agency

Name 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 calls

Please 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 daily

Please enter a number from 0 to 100.

Please list average number of QRV units in service daily

Staffing shortage*

Is your agency experiencing an increase shortage with staffing?

Staffing comment box

Please 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 COVID

Please enter a number from 0 to 50.

Number of staff awaiting COVID results*

Please list number of staff awaiting COVID results

Please 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

Please 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/policy

Please 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?)

Nurse triage line available in your jurisdiction/county?*

Do you know of a nurse triage line for COVID19 in your jurisdiction/county?

General comments

Please list any concerns or comments here