Healthcare Resource Assessment - EMS (Responses)
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TimestampEmail Address1. Agency Name:
2. Jurisdiction(s) Covered (please select all that apply):
3. 24/7 Primary Agency Contact Name:
4. 24/7 Primary Agency Contact E-mail:
5. 24/7 Primary Agency Contact Phone:
6. 24/7 Alternate Agency Contact Name:
7. 24/7 Alternate Agency Contact E-mail:
8. 24/7 Alternate Agency Contact Phone:
9. Total number of paramedics *please include volunteer and paid*:
10. Total number of EMTs *please include volunteer and paid*:
11. Please list any other staff types within your agency (e.g., doctors, nurses, etc.):
12. Average number of staffed BLS ambulances per day:
13. Average number of staffed ALS ambulances per day:
14. Do you have staff that can administer vaccines to adults?
15. Do you have staff that can administer vaccines to children?
16. Please list any specialty teams/capabilities within your agency not captured above:
17. How many Duodotes does your agency currently have?
18. How many Cyanokits does your agency currently have?
19. Please upload your medical related supply cache inventory list(s), and locations, to the following Google folder: https://drive.google.com/drive/folders/1V5_Jch7rIgvLJycFkkR-EjwRvAapURNM?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please email your inventory list to SWCHCC@gmail.com
20. If already documented, please upload your Medical Related Supply Cache Mobilization Process to the following Google folder: https://drive.google.com/drive/folders/1CweHatP-sgCzlpxIpnHFZDLcw5L1rdFJ?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please email your mobilization process to SWCHCC@gmail.com.
21. Please list any current MOUs that you have in place with suppliers to provide priority in disaster events:
22. Please list the types and quantities of infectious disease PPE that your agency has on hand or upload to the following Google folder: https://drive.google.com/drive/folders/1gLkaXKJKUYCwJYbrdGv8JmYHP-yqHPp3?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please email your infectious disease PPE list to SWCHCC@gmail.com
23. How many staff are trained and fitted to utilize infectious disease PPE?
24. Total number of licensed ambulance vehicles, including those that are not staffed:
25. Total number of licensed EMS specialty vehicles:
26. Total number of command vehicles:
27. Total number of equipped EMS bikes:
28. Total number of MCI vehicles/trailers - please note if they are managed by another entity (e.g., RETAC):
29. Total number of HazMat vehicles:
30. Total number of fire rehab vehicles:
31. Total number of gators/ATVs:
32. Total number of multi-patient transport vehicles (medical bus and/or MCI bus):
33. Please list all types and quantities of HazMat radiation assets (detection/survey equipment):
34. Total number of evacuation sleds (e.g., Med Sleds):
35. Total number of stair chairs:
36. Please list any bariatric equipment housed within your agency:
37. Please list any pediatric evacuation resources housed within your agency:
38. Which communication modalities currently exist within your agency (select all that apply)?
39. Please select all radio capabilities currently available within your facility:
40. Number of portable or mobile radios programmed/operational within the Southwest region's standard EMS zones:
41. Number of portable or mobile radios programmed to be interoperable within the Southwest region (outside of EMS):
42. Dispatch: which entities provide dispatch for your agency?
43. Dispatch: Please provide contact info for your dispatch agency/agencies:
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