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Prioritizing COVID-19 testing in Long Term Care

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* 1. Full Name:

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* 2. Title:

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* 3. Community:

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* 4. COVID-19 testing can be administered by an RN, LPN or Delegated NAC or HCA. Would you have the available staff to conduct testing?

Yes

No

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* 5. Would you have the available staff to complete labeling of test samples and associated paperwork?

Yes

No

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* 6. Do you have the full PPE required (face shield, gloves, gown and mask)?

Yes

No

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* 7. Do you have a standing physician’s order for all residents to obtain testing?

Yes

No

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* 8. Do all of your residents have a Primary Care Provider?

Yes

No

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* 9. Do you have access to a medical director or physician who could provide orders for residents?

Yes

No

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* 10. If you have already completed testing (please select below)

Do you have staff who have refused to test?

Do you have residents who have refused to test?

N/A

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* 11. If you have not conducted testing, do you anticipate staff or resident refusals?

Yes

No

Comment:

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* 12. Additional comments: (optional)

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* 13. Address

Name

Company

Address

Address 2

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State/Province

ZIP/Postal Code

Country

Email Address

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