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CWH COVID-19 Survey
1.
Please provide your name and unit:
First and Last Name
What unit/department do you work?
2.
What is your number one issue with COVID-19?
3.
Have you been exposed to COVID-19 at work, either by taking care of a positive patient, positive patient family member or positive co-worker?
Yes
No
If yes, what procedure were you instructed to follow?
4.
Have you tested positive for COVID-19?
Yes
No
5.
Is your current PPE supply adequate?
Yes
No
If no, please provide details
6.
What types of PPE do you have available in your unit/department?
7.
How often do you change out your PPE?
8.
If your PPE is soiled or damaged, do you have easy access to a replacement?
Yes
No
If no, please provide details?
9.
If you are in an at risk or might be at risk category are you currently working with an accommodation?
Yes
No
10.
If you are in one of the high risk or might be at risk categories, did you see your family doctor and provide a note requesting an accommodation?
Yes
No
If no, please provide details?(Your personal medical condition is private. If your answer provides that information, we will keep it confidential.)
Thank you for taking the time to complete the survey. If you have any questions, feel free to contact Carmen Garrison, WSNA Nurse Representative, cgarrison@wsna.org.
