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Reporting Week
Please select the week you are reporting.
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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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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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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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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 specify
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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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