HomeMy WebLinkAboutcovid-19-facility-sit-stat-form-questions-reference-sheetAlameda County Medical Health Situational Status Report Form (COVID-19)
Reference List of Questions Asked on Electronic Form
Section 1: General Information
Facility Name
Facility Address
Originator Name
Title
Department
Phone #
Email Address
Facility Type
1. Hospital 2. Clinic 3. Long Term Care Facility 4. Skilled Nursing Facility 5. Dialysis Center 6.Other
Is your EOC/HCC activated?
1. Not Activated 2. Virtually Activated 3. Partially Activated 4. Fully Activated
EOC/HCC Phone #
EOC/HCC Email (if applicable)
Section 2: COVID-19 Patients and Testing Ability
Does your facility have the ability to test for COVID-19?
1.Yes, we can test at our facility
2.Yes, we can test through an affiliated facility
3.Yes, we have contracted through a private lab for testing
4.No, we do not currently have the ability to test
How many COVID-19 positive patients have you seen at your facility? (Cumulative Number)
How many COVID-19 positive patients are currently admitted at your facility?
Have any of your staff tested positive for COVID-19? (Since last Sit Stat submission)
1. Yes 2. No
Section 3: Facility Capacity/Capability
How many negative pressure isolation beds do you have at your facility?
Has your facility activated your surge plan to increase capacity?
1. Yes (please specify steps below) 2. No
If yes, what specific steps have you taken?
Do you have a physician/nurse triage line for your patients to access?
1. Yes 2. No
Do you have a telemedicine capability for at-home COVID-19 patients?
1. Yes 2. No
Section 4: Receiving of Patients
Please fill out the below questions on your initial submission. On subsequent submissions only fill out if
your process or plan has changed.
What is your facility's process for receiving a patient that may be a suspected PUI or confirmed COVID-
19 patient? (walk-in and by ambulance if applicable)
For patients who are not suspected to be PUI or COVID-19 patients, has there been any change in how
those patients are received at your facility? If yes, what is the new process?
Section 5: Urgent Care and Clinic Alternatives
Do you have or are you affiliated with urgent care services that may be appropriate to receive low acuity
patients with no cold/flu like symptoms (non-flu/COVID-19 patients) by ambulance?
1.Yes 2. No
Do you have or are you affiliated with non-urgent care clinics that may be appropriate to receive low
acuity patients with no cold/flu like symptoms (non-flu/COVID-19 patients) by ambulance?
1.Yes 2. No