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COVID- 19 Nursing Workplace Survey
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1.
Name of the facility in which you work
(Required.)
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2.
What type of department/unit do you work in?
(Required.)
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3.
Do you work at a facility that has cared for patients with known or suspected COVID-19?
(Required.)
Yes
No
Unsure
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4.
Have you provided direct care to a patient with known or suspected COVID-19?
(Required.)
Yes
No
Unsure
5.
How were you informed that you would be caring for a patient with suspected or confirmed COVID-19, including who informed you and when, in relation to your shift?
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6.
Has management communicated actions to take if you believe you have been exposed to a patient with known or suspected COVID-19 or if you exhibit symptoms (e.g., fever, cough, shortness of breath)?
(Required.)
Manager notified me
Employee Health notified me
I learned from the media
Nobody notified me
Other
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7.
What steps did the employer recommend you take?
(Required.)
Follow CDC guidelines
Follow advice from employee health
I still have unanswered questions
Other
Comment
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8.
Were you instructed to stay home from work? (check all that apply)
(Required.)
I was furloughed
I was told to stay home by my manager
I was told to stay home by employee heatlh
I chose to stay home
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9.
f you were instructed to stay home from work, is the employer paying you or did the employer instruct you to use PTO/EIB or file for worker’s compensation?
(Required.)
My employer is paying me
Using my PTO or EIB
I don't know
My employer instructed differently
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10.
Currently, do you feel prepared to provide care for a patient with known or suspected COVID-19?
(Required.)
Yes
No
Unsure
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11.
Does your facility have a plan in place to care for those with known or suspected COVID-19?
(Required.)
Yes
No
Unsure
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12.
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?
(Required.)
Yes
No
Unsure
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13.
Does the facility have negative air pressure rooms?
(Required.)
Yes
No
Unsure
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14.
Do you know where they are located?
(Required.)
Yes
No
Unsure
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15.
Does the facility have N95 respirators available?
(Required.)
Yes
No
Unsure
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16.
Is yearly N95 respirator fit testing been provided?
(Required.)
Yes
No
Unsure
My unit uses another type of respirator that does not require fit testing (i.e. CAPR)
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17.
Does your facility have PAPRs or reusable respirators?
(Required.)
Yes
No
Unsure
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18.
Do you have access to adequate supplies of PPE (respirators, eye protection, face shield, gloves) to do your work?
(Required.)
Yes
No
Unsure
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19.
Has management assigned/asked for staff volunteers dedicated to care for patients with COVID-19?
(Required.)
Yes
No
Unsure
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20.
Has your management/supervisor discussed with frontline staff your facility’s response plan for caring for patients with known or suspected COVID-19?
(Required.)
Yes
No
Unsure
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21.
What type of preparation and training has your facility conducted? (check all that apply)
(Required.)
Adding questions to intake screening
Posting of CDC checklist for patients with known or suspected COVID-19 on your unit
Posting phone number of state Department of Health
Plan for patient transport from clinic/community to ED
Plan for patient transport from ED to inpatient setting
Setting up separate screening areas for potential patients
Setting up isolation areas specific for patients with known or suspected COVID-19
CDC recommended personal protective equipment (PPE) is immediately available to staff
CDC recommended PPE kits ready for use and practice for clinic, public health, ambulatory setting
CDC recommended PPE kits ready for use and practice for ED or Urgent Care setting
Training staff on current infection control protocols
Employer-provided training on when to use PPE, donning, and doffing
Discussed safety and patient care delivery in daily huddle
Clinical protocols for aerosol-generating procedures (bronchoscopy, intubation, CPR, respiratory suctioning, etc.)
Appropriate cleaning materials
I don't know
Other (please specify)
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22.
If training is being conducted, what methods of instruction are being used?
(Required.)
None
General meetings/forums
Literature provided
Videos
Webinars
Inservices/huddles
Review of updated PPE procedures
Repetitive hands-on drills appropriate to your role including donning and doffing PPE
