State:* must provide value
Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Agency Name:* must provide value
Number of EMS personnel (EMR, EMT, Nurse, Paramedic, Etc) within the Agency* must provide value
Agency Contact Phone Number: * must provide value
Name of Agency Point of Contact: * must provide value
CONFIRMED NEW (Past 7 days): Record the number of EMS personnel in your agency that tested positive with COVID-19 in the past 7 days (confirmed by laboratory test).* must provide value
The response to the following will be an actual number (1 to 4 digits).
TOTAL CONFIRMED: Record the number of EMS personnel in your agency that are currently positive with COVID-19 (confirmed by laboratory test). This number includes all positive personnel in the past 7 days and personnel CONFIRMED positive that have not had a follow-up negative test.* must provide value
The response to the following will be an actual number (1 to 4 digits).
SUSPECTED: Record the number of EMS personnel in your agency that are being quarantined or prevented from working in the past 7 days due to suspected COVID-19 (have not had a positive test). * must provide value
The response to the following will be an actual number (1 to 4 digits).
COVID-19 DEATHS: Record the number of EMS personnel in your agency with SUSPECTED or laboratory CONFIRMED COVID-19 who died in the past 7 days.* must provide value
The response to the following will be an actual number (1 to 4 digits).
EMS PERSONNEL: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), Paramedic* must provide value
Yes
No
Please select Yes or No
EMS PERSONNEL: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), Paramedic* must provide value
Yes
No
Please select Yes or No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic? * must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request for this item through the Emergency Management process, has your request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request for this item through the Emergency Management process, has your request been filled? Yes, Complete Order
Yes, Partial Order
No
Are you currently re-using the item or implementing extended use? * must provide value
Yes
No
Please select Yes or No
Are you able to obtain this item through your normal purchase procedure? * must provide value
Yes
No
Please select Yes or No
Have you submitted any requests for resupply through your Emergency Management or Public Health process since the beginning of the COVID-19 pandemic?* must provide value
Yes
No
Please select Yes or No
If you have submitted a request, has your most recent request been filled? Yes, Complete Order
Yes, Partial Order
No
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