COVID 19 Monitoring Questionnaire
General Information
1.
Name of Provider
2.
Name of Provider Staff Member
3.
Contact Information (email and/or phone)
Environment and Supplies
4.
What is your current policy regarding cleaning/disinfecting facilities?
5.
How many supplies does the facility have on hand (PPE, cleaning/disinfecting supplies, etc.)?
6.
Have you attempted to pre-order medications and other supplies for residents?
Staff
7.
Are you screening or testing staff for COVID-19?
8.
Have any staff tested positive? If so, how many/when/current status?
9.
What is your policy if a staff member shows symptoms of COVID-19?
10.
Have any staff stopped working due to being at risk of contracting COVID-19? (Including due to being in a high risk group or caring for a person in a high risk group?)
11.
What are your current staffing levels?
12.
How many back up staff do you have available?
13.
What contingency plans do you have if a staff member test positive?
14.
Are you providing training to staff on COVID-19? If so what training?
Residents
15.
Are you educating residents about COVID-19? If so, how?
16.
Are you screening or testing residents for COVID-19?
17.
What is your policy if a resident shows symptoms of COVID-19?
18.
Have any residents tested positive? If so, how many/when/current status?
19.
What contingency plans do you have if a resident test positive, including plans for isolation rooms/quarantine rooms?
20.
Do residents have access to a phone or computer where they can contact friends, family in lieu of visitation, and us if needed?
21.
What contingency plans do you have in place in case there is a shelter in place order?
22.
At this time is there anything that you believe would help you better serve your residents?