EHPC Essential Elements of Information (EEI) EHPC Essential Elements of Information (EEI) This form is to be completed during a disaster or event Date* MM slash DD slash YYYY Please complete the date your facility completed this form.Time* : Hours Minutes AM PM AM/PM Please complete the time your facility completed this form.Email Address* Please enter the email address of the person completing the form.Facility Name* Please input the name of your hospital or organizationPhonePlease add a phone number where you can be reached for questions.Status* Open Closed Check the box that indicates your current status.Structure Stable? Yes No Concerned Unknown Check the box that indicates your facilities structure stability.Oxygen Bar?* Yes No Does your facility have people there to just get oxygen?Number of Boarding* How many people are being "boarded" at your facility?Number of Licensed Beds* How many licensed beds does your facility have?Number of Staffed Beds* How many of your beds are currently staffed?Total Census* What is your current census of your facility?Pediatric Beds (SKIP IF N/A) How many Pediatric beds does your facility have. How many Pediatric Patients do you have? (i.e. 10 beds / 4 patients)Pediatric ICU Beds (SKIP IF N/A) How many Pediatric ICU beds does your facility have? How many beds are occupied? (i.e. 4 beds / 2 patients)Nursery Beds (SKIP IF N/A) How many Nursery beds does your facility have?NICU Beds (SKIP IF N/A) How many NICU beds does your facility have? How many beds are occupied? (i.e. 4 beds / 2 patients)ICU Beds* How many ICU beds does your facility have? How many beds are occupied? (i.e. 4 beds / 2 patients)Number on Ventilators* How many Patients are on Ventilators in your facility?Number in ED* How many patients are in your Emergency Department?Adult Medical Surge Floor Beds How many Adult Medical Surgical Floor Beds does your facility have?Psychiatric Beds How many Psychiatric Beds does your facility have?Rehab Beds How many Rehab Beds does your facility have?Staff other Boarding How many extra staff is your facility housing?Power Type* Commercial Generator Without What type of power is your facility currently operating on?Generator Fuel Type* Diesel Gasoline Gas (Natural or LP) Gas & Diesel Other Unknown What type of fuel does your generator run on?Fuel Status Storage on Hand (Gallons)* How much fuel is your facility storing that is available (Gallons)?Estimated Run Time (Hours)*How long do you estimate your fuel supply to last in Hours?HVAC Functional* Yes No Unknown Is your HVAC functional at the current time?Communications Operational* Yes No Unknown Is your communications currently operational?Communication NeedsDoes your facility have any current needs for communications?Blood Products Sufficient?* Yes No Unknown Does your facility have a sufficient amount of Blood Products for this event?Blood Cell Type and NumberWhat type of Blood Cells are you stocking and How many do you have on hand?Operating Room Status?* Operational Closed Not Applicable What is the current status of your facilities operating room (if equipped)?Water Supply* Yes No Unknown Does your facility have a sufficient amount of water on hand?Food Supply*Does your facility have a sufficient amount of food, if so how many days do you have on hand?Morgue Capacity*What is the capacity of your facilities morgue?Notes:Please add any questions, notes, or information we may need to know or answer for your facility. updated 1/13/2020
