Survey Questions final

OMB Control No. 0910-0500

Expiration Date: 9/30/2023

Paperwork Reduction Act Statement:  According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0910-0500 and the expiration date is 09/30/2023.  The time required to complete this information collection is estimated to average 15 minutes, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden, to PRAStaff@fda.hhs.gov.

The survey we are conducting is on behalf of the U.S. Food and Drug Administration (FDA).

COVID-19 Critical Care Drug Monitoring Survey
Survey Submitter Information
*Submitter First Name		Submitter Middle Name		*Submitter Last Name
Submitter Country		Submitter Phone Number		*Submitter Role
Hospital/Organization Information
*Hospital/Organization Name		Address Line 1		Address Line 2
City		*State		*Zip or Postal Code
Hospital/Organization Details
*Number of Hospitals Represented in Survey?		Number of Hospital Beds
*Does the Hospital have an ICU?		Number of ICU Beds
*State(s) represented in this survey?
*Approximate Number of COVID-19 Patients
Number of ICU COVID-19 Patients (non-ventilated)
Number of ICU COVID-19 Patients (ventilated)
*FDA Critical Care Drug List
Drug Name	Route of Administration	*What is Your On-Hand Day Supply?	Is there a Particular Concentration for this Drug?	Are you Changing Medical Practice to Manage Supply?	Are you Experiencing Delays in Receiving the Drug?
Rocuronium	Injection
Succinylcholine	Injection
Norepinephrine	Injection
Phenylephrine	Injection
Vasopressin	Injection
Azithromycin	Injection
Ceftriaxone	Injection
Piperacillin/Tazobactam	Injection
Vancomycin	Injection
Doxycycline	Injection
Albuterol MDI	Inhalation
Albuterol Neb	Inhalation
Ipratropium/albuterol	Inhalation
Dextrose 5% Water	Injection
Normal Saline 0.9%	Injection
Lactated Ringers	Injection
Enoxaparin/LMWH	Injection
Alteplase	Injection
Acetaminophen	Injection
Amiodarone	Injection
Tocilizumab	Injection (Actemra)
FDA COVID-19 Critical Care Drug on FDA Shortage List (Optional Survey)
Drug Name	Route of Administration	What is Your On-Hand Day Supply?	Is there a Particular Concentration for this Drug?	Are you Changing Medical Practice to Manage Supply?	Are you Experiencing Delays in Receiving the Drug?
Cisatracurium	Injection
Vecuronium	Injection
Dexmedetomidine	Injection
Midazolam	Injection
Propofol	Injection
Ketamine	Injection
Fentanyl	Injection
Hydromorphone	Injection
Morphine	Injection
Epinephrine	Injection, Auto-Injector
Epinephrine	Injection, 0.1 mg/mL
Azithromycin	Oral
Cefepime	Injection
Cefotaxime	Injection
Heparin/UFH	Injection
Famotidine	Injection
Famotidine	Oral
Dexamethasone	Injection
Sodium Bicarbonate	Injection
Sodium Chloride 23.4%	Injection
Hydralazine	Injection
Pantoprazole	Injection
Enalaprilat	Injection
Phoxillum	CRRT Solution
PrismaSol	CRRT Solution
Additional Drugs Not Listed
*Drug Name		What is Your On-Hand Day Supply?	Is there a Particular Concentration for this Drug?	Are you Changing Medical Practice to Manage Supply?	Are you Experiencing Delays in Receiving the Drug?
Additional Comments