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HCAOA Illinois Chapter COVID & PPE Survey
Name
(Required.)
Agency Name
(Required.)
Title
(Required.)
Email Address
(Required.)
Number of Employees
<25
25-50
50-99
99+
Has your local health department recognized your employees as part of the 1A vaccination priority list?
Yes
No
Comments
What barriers are you experiencing in vaccinating your employees? Select all that apply.
Limited Availability
Local Health Department Restricting Access
Employee Refusal
Other, please explain
Is COVID testing available to employees in your area?
Yes
No
Comments
What barriers are your employees experiencing related to COV ID testing? Select all that apply.
Transportation
Cost/Copay
Employee Refusal
Other, please explain
Which PPE does your agency use? Please select all masks that your agency uses.
N95 Masks
KN95 Masks
3 ply medical masks
3 ply surgical masks
All of the above
Please select all gloves that your agency uses.
Vinyl
Nitrile
All the above
None of the above
Please select all liquids that that your agency uses.
Gel sanitizer
Isopropyl alcohol
Hydrogen peroxide
All the above
None of the above
Please select all wipes that your agency uses.
Disinfecting wipes
None of the above
Please select all gowns that your agency uses.
Disposable CPE Gowns Grade 1
Disposable CPE Gowns Grade 2
Disposable Isolation Gowns Grade 1
Disposable Isolation Gowns Grade 2
All the above
None of the above
Please select any other miscellaneous PPE that your agency uses.
Digital Thermometers
IR Thermometers
Other (please specify)
Does your agency use face shields?
Yes
No
Where have you been able to acquire PPE? Select all that apply.
Local health department
Big box stores (i.e. Walmart, Home Depot, Walgreens)
Private vendor
Vendor through HCAOA website
Other (please specify)
Have you been limited on the amount of PPE purchased based on previous orders?
Yes
No
Comments
Can you provide an estimate on the per item pricing you've paid or seen for the following PPE? Please provide as much information as you can.
N95 Masks
KN 95 Masks
3 ply medical masks
3 ply surgical masks
Vinyl Gloves
Nitrile Gloves
Gel sanitizer
Isopropyl alcohol
Hydrogen peroxide
Disinfecting wipes
Disposable CPE Gowns Grade 1
Disposable CPE Gowns Grade 2
Disposable Isolation Gowns Grade 1
Disposable Isolation Gowns Grade 2
Digital Thermometers
IR Thermometers
Faceshields
Would you be interested in working with a PPE supplier that offers HCAOA members special pricing with a promo code?
Yes
No
