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* 1. Facility Information

Please submit the following information every Monday.

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* 5. Identify the reporting period for your survey response

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* 6. Date submitted

Date

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* 7. Total number of staff (include contract staff, please use numeric value):

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* 8. Total number of fully vaccinated staff:

"Fully vaccinated": people are considered fully vaccinated for COVID-19 ≥2 weeks after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna), or ≥2 weeks after they have received a single-dose vaccine (Johnson & Johnson [J&J]/Janssen)±;

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* 9. Total number of partially vaccinated staff:

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* 10. Total number of unvaccinated staff with an approved exemption to the Public Health Order:

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* 11. Total number of unvaccinated staff without an approved exemption to the Public Health Order:

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* 12. Total number of current residents:

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* 13. Total number of fully vaccinated residents:

"Fully vaccinated": people are considered fully vaccinated for COVID-19 ≥2 weeks after they have received the second dose in a 2-dose series (Pfizer-BioNTech or Moderna), or ≥2 weeks after they have received a single-dose vaccine (Johnson & Johnson [J&J]/Janssen)±;

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* 14. Total number of partially vaccinated residents:

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* 15. Total Number of Residents who have not received vaccination due to a medical or religious reason?

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* 18. Do you need assistance with arranging booster doses?

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* 19. Do you have enough Curative test kits to complete this week's testing percentage?

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* 20. Do you have rapid test kits on-hand should you need those to supplement  test kits from Curative?

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