EHPC Regional Hospital EEI COVID19

Date*

Please enter the date your facility completed this form.

Time*

Please enter the time your facility completed this form.

:

Hospital Name*

Please select facility from drop down list

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

Is facility EOC open?*

Check the box that indicates if your facility EOC is open

Yes
No

EOC comments

Feel free to enter any comments related to your EOC being open or closed here

What level is your EOC?*

Please select level of EOC operations. Reference can be found at https://www.cdc.gov/cpr/eoc/how-eoc-works.htm

What facility elective services are still open?*

Please select elective services still open at your facility

OR (Electives only)
GI
Cardiac cath lab
Outpatient cancer treatment
Pulmonary lab
Outpatient clinics
Outpatient radiology
N/A

Number on Ventilators on hand*

How many total ventilators are on hand in your facility?

Ventilators in use*

Please enter number of ventilators in use in your facility

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

Surge in flu like illness*

Has your facility seen a surge in flu like illness? (Other than normal seasonal volume?)

Staffing shortage*

Is your facility experiencing an increase shortage of staffing?

Staffing comment box

Please enter any comments here related to staffing

Number of positive COVID patients*

How many positive COVID-19 inpatients does your facility currently have?

Please enter a number from 0 to 1000.

Number of pending COVID tests*

How many inpatients are pending COVID-19 testing at your facility?

Please enter a number from 0 to 1000.

ED Volume*

Is your Emergency Department volume currently

Patient Acuity*

Is your general patient acuity

higher than normal
normal
lower than normal

Morgue Capacity*

What is the morgue capacity at your facility?

Please enter a number from 0 to 1000.

Morgue Census*

Please enter a number from 0 to 1000.

What is the current census in your facility’s morgue?

Number of long term decedents (awaiting state lab results) etc*

Please list number

Please enter a number from 0 to 100.

Are you having issues with funeral homes picking up decedents?*

Please select if any pickup issues are occurring

Please describe issues with decedent(s) pickup*

Please describe in detail issues occurring

PAPRs*

How many PAPRs does your facility have on hand?

Adequate
Running Low
Zero

CAPRs*

How many CAPRs does your facility have on hand?

Adequate
Running Low
Zero

EHPC Hospital EEI COVID19