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Reporting Week
Please select the week you are reporting.
An answer is required
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Agency Name
Please list your agency's official name (No abbreviations). |
Contact Person
Please list the name and email address of the person completing this report. |
County
Please list the county (or counties) your agency serves.
Atlantic
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Bergen
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Burlington
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Camden
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Cape May
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Cumberland
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Essex
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Gloucester
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Hudson
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Hunterdon
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Mercer
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Middlesex
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Monmouth
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Morris
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Ocean
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Passaic
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Salem
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Somerset
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Sussex
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Union
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Warren
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Please select {0} response(s)
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Personnel
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What is your total number of personnel?
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How many of your personnel are currently out sick due to testing positive for COVID-19?
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How many of your personnel have been hospitalized due to COVID-19?
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How many of your personnel are currently out due to self-quarantine for possible COVID-19 exposure?
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How many of your personnel are currently out due to other reasons?
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How many of your personnel were previously quarantined and have since returned to full duty?
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Have any of your personnel succumbed to a COVID-19 related illness?
Yes
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No
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An answer is required
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If you have had COVID-19 personnel deaths, have you reported them to the NJDOH / ESF 8 desk?
Yes
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No
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An answer is required
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Resources
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What other resources does your department forecast may become critical?
NONE
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Personal Protective Equipment (PPE)
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Medical Supplies
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Support Personnel
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Other (please list resource)
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Please select {0} response(s)
Please specify An answer is required
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Has your agency utilized, or are they currently utilizing, any of the following waivers?
NONE
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BLS Triage to Home
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ALS Triage to Home
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BLS Crewmember Requirements
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MICU Crewmember Requirements
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SCTU Crewmember Requirements
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Unlicensed Vehicle
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Out of State BLS Provider
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BLS Certification Extension
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Expired EMT Re-Entry - COVID19
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Authorization for Paramedics to Work in Hospital Setting
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ALS Certification Extension
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Inactive to Active Paramedic
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Expired Paramedic Re-Entry - COVID19
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Executive order of One Paramedic Pronouncement
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Please select {0} response(s)
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