EHPC PPE Capability Assessment Regional PPE Capability Assessment This list of questions is being used to help determine and assess your agency's need, related to your WebEOC (Sparta) request for PPE assistance. Please reach out to partner agencies and your suppliers, across county/state lines and think outside of the box on options for securing supplies. Once completed, your request will be validated and matched with the appropriate resources as available. Name* First Last Your Agency*Email* WebEOC (Sparta) Request Number*Direct Phone Number*Do you have active COVID patients in your County?*Please list number of active COVID patients in your CountyYesNoNumber of active COVID patients in your county*Please list number of active patients in your countyPlease enter a number from 1 to 500.Do you have COVID patient in your facility/hospital?*Please select if your facility has an active COVID patient(s)YesNoN/AHow many active COVID patients in facility?*Please list numerical amountPlease enter a number from 1 to 500.If EMS agency/system- How many EMS units does your county in service?Please list number of EMS units in servicePlease enter a number from 1 to 50.If EMS agency/system- What is your average daily call volume?Please list call volumePlease enter a number from 1 to 500.Personal Protective EquipmentPlease Indicate Below by checking the box next to the PPE Your facility uses. THEN INDICATE THE CURRENT BURN RATE (How many do you use per day). We also need to know how many days of supplies you currently have on hand of the following items.WHICH PPE IS YOUR FACILITY / AGENCY REQUESTING?Check all that apply to your agency Powered Air-Purifying Respirator (PAPR) Controlled Air-Purifying Respirator (CAPR) N95 Ear Loop Mask (Surgical) Face Shields Safety Glasses/Goggles Disposable Gowns Nitrile Gloves - Small Nitrile Gloves - Medium Nitrile Gloves - Large Nitrile Gloves - X Large Shoe covers If you are requesting N95 masks, what are you using them for?*Please list in detail what you are using the N95 masks for What vendors are you ordering your needed PPE supplies from?*Please list the PPE expected delivery date for each item requested.*How many PAPR's does your agency currently have?PAPR Supply Burn rate per day?Include the following: Disposable Hoods, Butyl Hoods, Reusable Hoods, Single-use Batteries, Rechargeable Batteries, HEPA Filters, CBRN Filters, Suit Kits (sizes), OTHER ITEMS NOT LISTED.How many CAPR's does your agency currently have?CAPR Supply Burn rate per day?Include the following: Disposable Hoods/Filter Packs & sizes, Rechargeable Batteries, Bio Suits (sizes) OTHER ITEMS NOT LISTED.What Manufacturer, Standard or Duckbill, Size, and Model of N95 does your agency use?What is your agencies current burn rate for N95's?How many N95's does your agency currently have on hand?What is your agencies current burn rate for Ear Loop Mask's?How many Ear Loop Mask's does your agency currently have on hand?What is your agencies current burn rate for Face Shields?How many Face Shields does your agency currently have on hand?How many Safety Glasses/Goggles does your agency currently have on hand?What is your agencies current burn rate for Disposable Gowns?How many Disposable Gowns does your agency currently have on hand?What is your agencies current burn rate for Nitrile Gloves - Small?How many Nitrile Gloves - Small does your agency currently have on hand?What is your agencies current burn rate for Nitrile Gloves - Medium?How many Nitrile Gloves - Medium does your agency currently have on hand?What is your agencies current burn rate for Nitrile Gloves - Large?How many Nitrile Gloves - Large does your agency currently have on hand?What is your agencies current burn rate for Nitrile Gloves - X Large?How many Nitrile Gloves - X Large does your agency currently have on hand?Does your agency have an established Respiratory Protection Program? Yes No Not Sure Who do you have trained to perform fit testing, if the PPE is approved?Do your facility/agency have a PPE reuse policy?*Please select if your facility has a reuse plan?YesNoIs your facility/agency collecting applicable PPE post use/shift?*Please select if any PPE is being collected post use or shift for re-use.YesNoN/AIf you selected yes, please describe how PPE is being collected/re-used*Please describe how PPE is being collected, cleaned and issued for re-use. We are specifically looking for data on N95s, eye shields and eye protection.
