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
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