EHPC Regional Hospital EEI COVID19 EHPC Hospital EEI COVID19 This form is to be completed during a disaster or event Date*Please enter the date your facility completed this form. MM slash DD slash YYYY Time*Please enter the time your facility completed this form. Hours : Minutes AM PM AM/PM Hospital Name*Please select facility from drop down list Carolina EastCarteret GeneralMartin General HospitalOnslow Memorial HospitalOuter Banks HospitalPAM Specialty Hospital of Rocky MountSentara Albemarle HospitalUNC LenoirUNC Nash HospitalVidant Edgecombe HospitalVidant Beaufort HospitalVidant Bertie HospitalVidant Chowan HospitalVidant Duplin HospitalVidant Medical CenterVidant North HospitalVidant Roanoke Chowan HospitalWashington County HospitalUNC Wayne HospitalWilson Medical CenterName 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 commentsFeel 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.htmLevel 1Level 2level 3Not openWhat 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 needsPlease 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?)YesNoNot sureStaffing shortage*Is your facility experiencing an increase shortage of staffing?YesNoStaffing comment boxPlease 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 higher than normal normal lower than normal N/A 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 numberPlease 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 YesNoPlease 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
