Forms

  

Name​

                        ​Description

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Index Hospital SBAR Form  (PDF)

Index Hospital SBAR Form (Word)

​To be completed by the Index Hospital’s critical care team (critical care manager, director or other delegate) and provided to the Hospital CEO/senior delegate prior to the Moderate Surge preamble call organized by CritiCall Ontario.​ The SBAR Tool provides a consistent method of reporting situations, which require escalation.
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Partner Hospital Reporting Form (PDF)

Partner Hospital Reporting Form (Word)

​To be completed by Partner Hospitals prior to joining the Moderate Surge teleconference (organized by CritiCall Ontario).​ This form has been developed to confirm resources available at the partner hospital in the event of a moderate surge.
pdf-icon.png Service Inventory Change Request Form (November 2019)   This form is to be completed by critical care units that are reporting substantive changes to their hospital’s critical care capacity information.​
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Requesting Hospital Checklist for Sending and Receiving Provincial Ventilators (PDF)

Requesting Hospital Checklist for Sending and Receiving Provincial Ventilators (Word)

​When accessing ventilators from the Provincial Stockpile, the Requesting Hospital is required to complete the Requesting Hospital Checklist for Sending/Receiving Ventilators (Form Three) upon receipt of the ventilator(s).  Any malfunction or damage to the ventilator(s) noted while completing the checklist at the Requesting Hospital must be reported immediately to the Host Hospital Site Lead to begin discussion on how best to coordinate timely repair of the ventilator(s). 
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Host Hospital Checklist for Sending and Receiving Provincial Ventilators (PDF)

Host Hospital Checklist for Sending and Receiving Provincial Ventilators (Word)

​For ventilators accessed from the Provincial Stockpile, the Host Hospital Checklist for Sending/Receiving Ventilators (Form Two) is required to ensure that all associated equipment (including consumables) required to safely operate the ventilator(s) is accounted for, and to document the physical condition of the ventilator(s) prior to release.  The Host Hospital must complete the checklist prior to shipping the ventilator(s) to the Requesting Hospital and upon receipt of the ventilators back from the Requesting Hospital.

Both the Host Hospital and Requesting Hospital should retain copies of these completed checklists for their records, and to provide if requested by CCSO or MOH.