*1. Name and Title of Person completing this form

Transcription

1 This survey is to assist in the RAC budget, planning, and regional priorities. This form replaces our Needs Assessment Form of previous years. THE DEADLINE is May 15th, 2015 Please at the end of the survey provide any unlisted equipment and/or training. *1. Name and Title of Person completing this form Name: Title:

2 *2. Please provide your contact information below. Name: Hospital / EMS Provider Name: CEO: City/Town: ZIP: Address: Phone Number:

3 *3. EMS Director: EMS Directors Name: Address: Phone Number: Fax Number: Cell Number:

4 4. Has your facility signed an MOA for potential EMTF / State Deployment? gfedc Yes gfedc No

5 5. EMS DIVISION QUESTIONS How many ambulances of each type do you have? BLS ALS MICU FIXED WING ROTARY CRAFT SPECIALTY CARE TRANSPORT RESERVE VEHICLES 6. CONTINUED... How many ambulances of each type do you have staffed within a 24 Hour timeframe? BLS ALS MICU FIXED WING ROTARY CRAFT SPECIALTY CARE TRANSPORT RESERVE VEHICLES 7. CONTINUED... Number of staff on call? BLS ALS MICU FIXED WING ROTARY CRAFT SPECIALTY CARE TRANSPORT RESERVE VEHICLES

6 8. CONTINUED... How many runs per month do you make? BLS ALS MICU FIXED WING ROTARY CRAFT SPECIALTY CARE TRANSPORT RESERVE VEHICLES 9. CONTINUED... Do you have ambulances that are reserved for EMTF / State Deployment? Please answer Yes or No BLS ALS MICU FIXED WING ROTARY CRAFT SPECIALTY CARE TRANSPORT RESERVE VEHICLES 10. CONTINUED... Please list the number of EMS Employees trained in: MIST ASTL WebEOC RNST MMU TEAM

7 11. EMS EQUIPMENT NEEDS # On Hand Monitor / Defib Pulse Ox Backboards Trauma Bags Scoop Stretchers Traction Splints IV Fluid Warmer Ventilator Radios Shamu Lifts Pagers Computers Carbon Monoxide Oximeter Bed Sleds Other

8 12. CONTINUED... # Requested Monitor / Defib Pulse Ox Backboards Trauma Bags Scoop Stretchers Traction Splints IV Fluid Warmer Ventilator Radios Shamu Lifts Pagers Computers Carbon Monoxide Oximeter Bed Sleds Other 13. CONTINUED... # Available Monitor / Defib Pulse Ox Backboards Trauma Bags Scoop Stretchers Traction Splints IV Fluid Warmer Ventilator Radios Shamu Lifts Pagers Computers Carbon Monoxide Oximeter Bed Sleds Other

9 14. HOSPITAL / EMS EDUCATIONAL TRAINING NEEDS # Employed by Agency ACLS PALS ADLS BDLS NDLS ATCN ENPC TNCC ATLS PBTLS BTLS ECA / First Responder PEPP CISM NALS Decon Training NIMS WebEOC COOP (Continuity of Operations)

10 15. CONTINUED... # of Certified Staff ACLS PALS ADLS BDLS NDLS ATCN ENPC TNCC ATLS PBTLS BTLS ECA / First Responder PEPP CISM NALS Decon Training NIMS WebEOC COOP (Continuity of Operations)

11 16. CONTINUED... # Needing to be Trained ACLS PALS ADLS BDLS NDLS ATCN ENPC TNCC ATLS PBTLS BTLS ECA / First Responder PEPP CISM NALS Decon Training NIMS Mass Casualty / Mass Fatality ESAR VHP / TDVR WebEOC COOP (Continuity Of Operations)

12 17. CONTINUED... # Needing Training for Recertification ACLS PALS ADLS BDLS NDLS ATCN ENPC TNCC ATLS PBTLS BTLS ECA / First Responder PEPP CISM NALS Decon Training NIMS WebEOC COOP (Continuity of Operations) 18. Would you be interested in hosting a CISM (Critical Incident Stress Management) or COOP (Continuity of Operations) Training? nmlkj Yes nmlkj No 19. EBOLA Preparedness: Provide a list and quantity of PPE supplies that your facility would need in the event of new EBOLA or infectious disease preparedness efforts. Be prepared to provide separately, your choice of vendors/manufacturer(s) should the funding be made available. 5 6

13 20. Other comments or requests please list here: 5 6