Answers will be aggregated and identifying information will be removed from the final survey results. Updating your contact information allows an organizer to follow up to discuss what’s happening in your facility and how to address concerns identified by you and your coworkers.

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* 1. Name

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* 2. Employer

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* 3. Unit

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* 4. Job title

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* 5. Email

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* 6. Cell Phone

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* 7. Name of the facility in which you work:

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* 8. In which of the following are you based:

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* 9. What is your department/unit?

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* 10. Do you work at a facility that has cared for patients with known or suspected COVID-19?

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* 11. Have you provided direct care to a patient with known or suspected COVID-19?

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* 12. If you did provide direct care to a known or suspected COVID-19 patient, how were you informed that you would be caring for them? Include who informed you and when, in relation to your shift.

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* 13. If you did provide direct care to a known or suspected COVID-19 patient, has management communicated actions to take if you believe you have been exposed or if you exhibit symptoms (e.g., fever, cough, shortness of breath)? (check all that apply)

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* 14. If management did communicate actions you should take due to exposure or exhibiting symptoms, what steps did the employer recommend?

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* 15. Were you instructed to stay home from work for being exposed to a known or suspected COVID-19 patient or being symptomatic? (check all that apply)

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* 16. If you were instructed to stay home from work, is the employer paying you or did the employer instruct you to use sick time/PTO/EIB, unpaid leave, or file for worker’s compensation?

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* 17. Currently, do you feel prepared to provide care for a patient with known or suspected COVID-19?

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* 18. Does your facility have a plan in place to care for those with known or suspected COVID-19?

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* 19. Is there a place in your facility to screen and triage patients who come into the facility to make sure that patients with possible COVID-19 are isolated?

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* 20. Is your facility having patients who exhibit COVID-19 symptoms wear masks when they enter the facility, including while they are in a waiting room?

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* 21. Has your facility adopted additional cleaning/sanitizing of public areas and waiting rooms?

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* 22. Has your facility communicated to you about additional cleaning/sanitizing and what specifically has been added to common practice?

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* 23. If your facility has communicated to you about this, please describe the additional cleaning/sanitizing services being practiced.

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* 24. Does your facility have contractors that provide environmental or janitorial services?

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* 25. Have you been told that you are responsible for additional cleaning/sanitizing?

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* 26. If you have been told you are responsible for additional cleaning/sanitizing, who informed you and when in relation to your shift?

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* 27. If additional cleaning/sanitizing practices are happening at your facility, do you feel comfortable that the practices you or others are doing are creating a safer environment for patients and co-workers?

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* 28. Have changes been made to the way food is being delivered to patients with known or suspected COVID-19? (check all that apply)

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* 29. If you work in a unit with known or suspected COVID-19 patients (including the Emergency Department), has your facility improved/increased Environmental Services staffing on your unit?

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* 30. Is your patient load being adjusted if you are assigned to care for a known or suspected COVID-19 patient?

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* 31. Does the facility have negative air pressure rooms?

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* 32. Do you know where they are located?

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* 33. Does the facility have N-95 respirators available?

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* 34. Is yearly N-95 respirator fit testing been provided?

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* 35. Does your facility have PAPRs or reusable respirators?

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* 36. Do you have access to adequate supplies of personal protective equipment (PPE) (respirators, eye protection, face shield, gloves) to do your work?

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* 37. Has management assigned/asked for staff volunteers dedicated to care for patients with COVID-19?

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* 38. What type of preparation and training has your facility conducted? (check all that apply)

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* 39. If training is being conducted, what methods of instruction are being used?

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* 40. Does the PPE you are using to treat suspected or confirmed COVID-19 patients require the assistance of a co-worker to remove?

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* 41. If the PPE does require the assistance of a co-worker to help remove it, has your staffing been adjusted to allow for that extra support?

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* 42. How is your unit/department/facility filling open shifts? (check all that apply)

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* 43. Are you afraid to come to work?

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* 44. On a scale of 1-5, how would you rate your facility’s communication to you and your coworkers regarding PPE and safety measures that are being taken throughout the hospital?

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* 45. How is your facility communicating with you and your coworkers? (check all that apply)

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* 46. What additional information do you need to feel safe and informed (e.g., effectiveness of employer response, resources, personal support)?

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* 47. Additional comments or things you would like to make sure are known:

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* 48. Would you like an organizer to follow up with you about your survey response?

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