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IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 General Information
Thank you for taking the time to complete this weekly report. Your responses help us better fulfill our mission.
Name of Organization:
Please identify yourself for contact if we have any questions regarding your response.
Please indicate the type of organization you represent:
Have you had any changes to the quantities on hand of antiviral and/or personal protective
equipment (i.e. have you dispensed, received, or distributed any of these items to/from
individuals and/or outside organizations)?
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for Antiviral Changes
Did the number of antivirals on hand change during this reporting period?
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for Personal Protective Equipment Changes
Did the number of Personal Protective Equipment on hand change during the reporting
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for Antiviral Distribution to External Partners
Did you distribute any antivirals to external partners (e.g. hospitals, health departments,
private physicians, EMS, fire, law enforcement, etc.)
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for PPE Distribution to External Partners
Did you distribute any PPE to external partners (e.g. hospitals, health departments, private
physicians, EMS, fire, law enforcement, etc.)
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for Antiviral Shortages.
A shortage is defined as having less than 72 hours supply of antiviral courses of treatments on hand, based on your current rate of H1N1 infection.
Based on the above definition do you currently have a shortage of Antivirals?
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Check for PPE Shortages.
A shortage is defined as having less than 72 hours supply of antiviral courses of treatments on hand, based on your current rate of H1N1 infection.
Based on the above definition do you currently have a shortage of Personal Protective
Equipment?
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Antiviral Statistics
For the inventory questions on this page, please report the number of regimens in cache for H1N1 response regardless of source (unless otherwise specified in the question).
Quantity of antivirals (Regimens/ courses of treatment) on hand:
Tamiflu, 75 mg (Oseltamivir) on hand from SNS Tamiflu, 75 mg (Oseltamivir) TOTAL AMOUNT ON Tamiflu, 45 mg on hand from SNS Distribution Tamiflu, 30 mg on hand from SNS Distribution Tamiflu, Oral Suspension on hand from SNS Tamiflu, Oral SuspensionTOTAL AMOUNT ON HAND Relenza (Zanamivir) on hand from SNS Distribution Number of Courses of Treatment of Antivirals Expiring in May 2010:
Quantity of Antivirals (Regimens/ courses of treatment) Distributed:
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 For this Reporting Period, please provide the Number of Antiviral Regimens dispensed for
each high-risk group*. If you are unable to report by high risk group, please provide only the
aggregate total dispensed to all high-risk groups, also if you did not dispense any regimens
to high-risk groups enter a zero in the aggregate total entry.
(*High-risk group: A person at high risk for complications to H1N1 infections is defined as
the same for seasonal flu at this time. As more epidemiological and clinical data become
available, these high risk groups may be revised).
Persons with chronic or immunosuppressive conditions* (include: chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus); immunosuppression, including that caused by medications or by HIV; persons younger than 19 years of age who are receiving long- term aspirin therapy; residents of nursing homes and other Total Regimens Dispensed to High Risk Groups IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Personal Protective Equipment Statistics
Quantity of Personal Protective Equipment on Hand For H1N1 Response (Recieved from the
SNS and agency cache)Please indicate number of units (individual masks, gowns, shields,
gloves, etc.) on all PPE:
Inovel 3000 Series (Moldex-Metrics) 3003 N95 Inovel 3000 Series (Moldex-Metrics) 3001 N95 Please list any additional PPE on hand for H1N1 respsonse not enumerated above.
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Quantities of Antivirals Distributed to External Partners
Quantity of Antivirals (by regimen) Distributed to External Partners (e.g. hospitals, health
department, private physicians, clinics, EMS, fire, law enforcement, etc):
Please list any additional antivirals you distributed to external partners.
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Quantities of PPE Distributed to External Partners
Quantity of Personal Protective Equipment (by individual unit) Distributed to External
Partners (e.g. hospitals, health department, private physicians, clinics, EMS, fire, law
enforcement, etc):
Inovel 3000 Series (Moldex-Metrics) 3003 N95 Inovel 3000 Series (Moldex-Metrics) 3001 N95 Please list any additional PPE you distributed to external partners.
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 External Partner Antiviral Distribution
Identify whether Community Partners Types were or were not shipped antivirals (Note-
ensure that healthcare providers/ facilities receiving product being used under an
Emergency Use Authorization (EUA) are directed to or provided with copies of required
documentation/ fact sheets):
Emergency Medical Services/ First Responder Federal (VA, Military Installations, etc) Other (please specify partner type(s) & item(s) shipped): Total number of shipments:
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 External Partner PPE Distribution
Identify whether Community Partners Types were or were not shipped PPE (Note- ensure
that healthcare providers/ facilities receiving product being used under an Emergency Use
Authorization (EUA) are directed to or provided with copies of required documentation/ fact
sheets):
Emergency Medical Services/ First Responder Federal (VA, Military Installations, etc) Other (please specify partner type(s) & item(s) shipped): Total number of shipments:
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Report Antiviral Shortage
A shortage is defined as having less than 72 hours supply of antiviral courses of treatments on hand, based on your current rate of H1N1 infection.
Please indicate the number of regimens necessary to correct the shortage you currently have. If you do not use a specific item, or you do not have a shortage (as defined above) please enter 0 (zero).
Please identify antiviral shortages (by regimen) in your agency/ jurisdiction
Please explain the nature of your antiviral shortages, if any.
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Report PPE Shortages
A shortage is defined as having less than 72 hours supply of antiviral courses of treatments on hand, based on your current rate of H1N1 infection.
Please indicate the quantity necessary to correct the shortage you currently have. If you do not use a specific item, or you do not have a shortage (as defined above) please enter 0 (zero).
Please identify PPE shortages (by individual unit) in your agency/ jurisdiction.
Inovel 3000 Series (Moldex-Metrics) 3003 N95 Inovel 3000 Series (Moldex-Metrics) 3001 N95 Please explain the nature of your PPE shortages, if any.
IDPH/OPR SNS Antiviral and PPE Weekly Report for 01/01 - 01/07 Thank You!
Please list your PREFERENCE type of N95 series masks.
Please be aware this is only a preference, while we will make every effort to supply
organizations with their preferred media, this may not always be possible in a public health
emergency.
Please list any additional comments or feedback below.

Source: http://prod.356ellb01.blackmesh.com/sites/default/files/public/php/427/427_survey.pdf

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