COVID-19 Forms & Information for Healthcare Partners
Sign-up to receive COVID-19 updates for healthcare partners here! (if you are already part of the Disaster Healthcare Partners Coalition you do not need to sign-up)
Weekly COVID-19 Healthcare Partners Conference Call slides can be found here.
Situation Report Forms
All Updated 3/24/20 for the use during COVID-19 response.
All healthcare facilities and non-medical partners requesting resources are required to submit a situation report prior to requesting resources. The situation reports are linked to the resource request (when you press submit it will take you to the resource request form). If you have questions about what situation report you should use you can contact the Public Health Department Operations Center by emailing: firstname.lastname@example.org
Outpatient Provider Situation Report Forms:
- Dialysis Center Situation Report
- Clinic (HCCs, FQHCs, CHCs), Urgent Care, Private Practice Situation Report
- Ambulatory Surgery Center Situation Report
- Home Health & Hospice Agency Situation Report
- EMS Provider Situation Report
Inpatient Provider Situation Report Forms:
Resource Request Process
Resource Request Signature Form ( Word, PDF) - Please submit one completed form for each facility/agency. This form identified authorized requestors from each organization and takes place of signing for each resource request. (added 3/29/20)
Resource Request for Staffing Resources- Complete and submit the following forms to email@example.com. Hospitals and Long Term Care Facilities need to complete the supplemental staffing request and the Hospital or Long Term Care Facility specific form. Other facilities only need to submit the supplemental staffing request form.
Over the past several weeks the Public Health Department has convened a group of healthcare partners, primarily made up of Healthcare Coalition Steering Committee members, Public Health Department experts and County Executive staff. This group has worked to identify which provider types are at the highest risk and a method for evaluating and distributing these needed resources fairly.
What does that mean for your organization?
The supplies your organization has requested are in scarce supply, there is no stockpile currently available that can meet the entire demand of our emergent and non-emergent healthcare system. To that end, we must make tough choices and limit the distribution of scarce medical resources we
have access to, based on a variety of risk factors. This could mean that your organization may receive a very limited number of supplies, or in some cases none at all.
How does this work?
The Scarce Medical Resource Committee developed a set of risk criteria to evaluate these requests, including: type of organization requesting supplies; exposure to COVID-19 patients; the ability isolate sick patients; average daily census; essential staff numbers; and the severity of the
need. While the system may not be perfect, it is designed to be fair and equitable, to do provide the most benefit, for the most people. In line with local and national guidance, we are allocating medical supplies to healthcare facilities/providers who have the greatest level of exposure. Other essential partners and medical services
will received supplies, but likely lesser quantities. We will continue to evaluate and evolve this model to meet the needs of our healthcare system.
The Public Health Department is reserving 20% of all scarce medical resources on-hand for future and emergency needs. An additional 10% of scarce medical resources are reserved for the disease containment efforts being done by the frontline public health staff. The remainder of
the scarce medical resources will be distributed to you and other partners.
Requests are broken down into four (4) risk tiers, based on the factors above. The highest tiered requests will receive the highest percentage of supplies, and the lowest tier will receive a much smaller percentage of supplies.
The Public Health Department is routinely making additional resource requests to the State to meet current and future scarce medical resource requests.
I didn't receive everything I asked for, now what?
As a reminder, this process is designed to be the "option of last resort". We will provide organizations as much of the requested resources as possible, following the above mentioned guidelines. The remainder of the request will be cancelled, there is no "back order". For example, if you ordered 1,000 isolation gowns, and received 75, do not expect the remaining 975 to be available at a later date. You will need to submit a new request. This is in-line with the State's resource request process. If you are still in need of scarce medical resources, we encourage you to continue to explore you traditional and non-traditional methods of procuring supplies. If that is not successful, please fill out another request.
Why do I have fill out a situation report with each request?
It is vital that the Public Health Department have a clear understanding of the healthcare system as the COVID-19 pandemic progresses. The situation reports provide vital information for us to evaluate and include in our situational updates to County and State leadership. This is also in-line with the State's resource request process.
When should I request supplies? How often can I fill out a request?
We request that you do your best to review your scarce medical resources early and often. The Public Health Department will be evaluating request twice per week, setting up delivery and pick-up options for both requests dates. Submitting urgent requests for immediate fulfillment should be a rarely used option. These types of requests require public health staff to redirect the fulfillment of other requests to meet this unanticipated urgent need, thus negatively impacting the entire process.