LTCF Survey

The Department would like to understand how many residential facilities have already done a test-based strategy or facilities that are pursuing a test-based strategy. In order to understand the testing environment in our residential facilities, we are requesting that each facility complete this LTCF testing survey.

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* 1. Please complete the following

Name of Facility

Address

City

Zip Code

County of Facility

Name of Facility Point of Contact

Name of Parent Company

Address of Parent Company

City

Zip Code

Name of Parent Company Point of Contact

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* 2. Who is your facility licensed with? [Check all that apply]

PA Department of Health

PA Department of Human Services

Federally licensed

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* 3. How many residents do you have in your facility?

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* 4. How many staff do you have in your facility?

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* 5. Does your facility have any active cases of COVID-19?

Yes