EMS Status Form

Name of Agency/Facility *

Address *

Street Address

Street Address Line 2

City State

Zip Code

County *

Point of Contact Name *

First Name Last Name

Point of Contact 24/7 Phone Number *

Area Code Phone Number

Point of Contact Email *

example@example.com

Total Daily Call Volume (Transport and Refusal) *

No. of Suspected COVID-19 Transports *

Under Investigation + Confirmed Positive

No. of Suspected COVID-19 Non-Transport (Refusal / Shelter in Place) *

Under Investigation + Confirmed Positive

No. of Staff on Duty Daily *

Are You Experiencing Staff Absenteeism? *

Yes No

If yes, reason for absences: Please put the number of each absence in the appropriate category. *

Quantity

Self illness

Mandatory quarantine

Family illness

School/daycare closure

If you are in need of additional PPE, please complete the request form by clicking this link: PPE Request

The PPE Form DOES NOT need to be completed daily. If you have already submitted a PPE Request, you do need to resubmit, unless explicitly requested by SETRAC. Thank you