Provider Relief Fund Survey Question Title * 1. What service lines do you offer? (Please check all that apply) Nursing home Assisted living Life plan community Home and community-based services Adult day services Home health Other (please specify) Question Title * 2. Did you apply to the U.S. Department of Health and Human Services for provider relief runds? Yes No Question Title * 3. If you applied for provider relief funds, have you received funds? Yes No N/A Question Title * 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) Question Title * 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) Question Title * 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? Question Title * 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) Question Title * 8. Please provide contact information. Name Organization City/Town State/Province Email Address Phone Number Done
