Weekly Hospice Data Collection & Reporting, v. 7/9/20 - part 1

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1. Please select your hospice

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2. Name of person completing this survey:

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3. How many COVID-19 patients has your hospice served to date? (Note: Please report serving COVID-19 patients to local health departments if these patients have not otherwise been reported.)

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4. Current Total Hospice Average Daily Census (ADC; excluding palliative or other patients):

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5. Current number of non-COVID-19 patients your hospice is serving (note: Q3 = Q4 + Q5):

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6. Current number of COVID-19 patients (tested positive, presumed, or recovered) your hospice is serving (note: Q3 = Q4 + Q5):

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7. Capacity: How many additional non-COVID-19 patients do you have capacity to serve?

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8. Capacity: How many additional COVID-19 patients do you have capacity to serve?

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9. Do you have a moment to answer additional patient capacity questions broken out by location of care?

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