Provider Relief Fund Survey

2.Did you apply to the U.S. Department of Health and Human Services for provider relief runds?

Yes

3.If you applied for provider relief funds, have you received funds?

Yes

N/A

4.If you have received funds, when pooled with other COVID-19 related funds your organization has received (e.g., FEMA, PPP, CARES Act funds from state or local governments, etc.), how would you characterize the amount you’ve received in comparison to your additional COVID-19 costs and lost revenues?

We received more than we need currently and don’t know if we will be able to spend it all by June 30, 2021

We have received sufficient funding to cover our organization’s additional COVID-19 expenses and lost revenues to date

We need more to adequately cover COVID-19 related expenses and losses incurred to date

Without additional funds, we may need to close or sell

N/A

Other (please specify)

5.If you haven't received provider relief funds, what reason were you given for not receiving funds?

TIN could not be validated

Ineligible for funds

Already received maximum amount for first half of 2020

N/A

Other (please specify)

6.If funds are still needed, approximately how much would your organization need to cover COVID-19 expenses and lost revenues to date not covered by other COVID-19 funds you’ve received?

7.What are the top 3 COVID-related items that are impacting your financial health? (Please check up to 3)

Significantly reduced occupancy

Lack of move-ins/admissions

Reduced level of service for in-home care

Operations have had to remain closed due to state/federal requirements

Covering cost of regular COVID-19 testing

Supporting vaccine administration

Covering ongoing personal protective equipment costs

Increased insurance costs (liability, employee health care, worker’s comp)

Other (please specify)

8.Please provide contact information.

Name

Organization

City/Town

State/Province

Email Address

Phone Number