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1. Full Name: (Required.)

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2. Title: (Required.)

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3. Community: (Required.)

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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?

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

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

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

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

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

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

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

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12. Additional comments: (optional)

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13. Address

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