CDPH is requesting health facilities to assist in evaluating capacity to respond to potential expansion of 2019-nCoV in California. CDPH requests that facility leadership complete this survey by the end of day, Wednesday, January 29, 2020.

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* 1. If you are a General Acute Care Hospital please select your facility

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* 2. If you are not a General Acute Care Hospital please enter your facility information

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* 3. In the event that you should have a Patient Under Investigation (PUI) tested or a confirmed case, please write in the cell/direct number and contact information of the administrator at your facility whom we can work with to coordinate a response (optional).

Designation of an individual as a facility’s contact is voluntary. To every extent possible, personally identifiable information submitted will be kept confidential subject to the provisions of state and federal laws including, but not limited to, the California Information Practices Act of 1977, and only used for the purposes stated herein.

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* 4. How many isolation rooms or private enclosed spaces do you have to isolate a patient?

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* 5. How many airborne infection isolation (negative pressure) rooms do you have for symptomatic patients? 

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* 6. How many rooms do you have which could be converted to temporary negative pressure isolation rooms using portable high-efficiency particulate air (HEPA) machines?

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* 7. Do you have adequate staffing to handle a PUI, a confirmed case, or potential multiple cases?

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* 8. Do you currently have adequate supplies (preferably up to 30 days of operational use) of personal protective equipment (PPE) for potential multiple cases? Please check all that apply.

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* 9. Are there other spaces in your facility, such as a floor or nursing unit that could be designated for the care of 2019-nCoV patients only, rather than placing them in airborne isolation rooms throughout the hospital, if the capacity for individual airborne isolation rooms is exceeded?

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* 10. Does your hospital's onsite clinical laboratory have the capacity to perform multiplex polymerase chain reaction (PCR) for viral pathogens, e.g., Biofire?

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* 11. Are there other factors or comments about your facility that are important for CDPH to know?

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