COVID 19 Monitoring Questionnaire General Information Question Title * 1. Name of Provider Question Title * 2. Name of Provider Staff Member Question Title * 3. Contact Information (email and/or phone) Environment and Supplies Question Title * 4. What is your current policy regarding cleaning/disinfecting facilities? Question Title * 5. How many supplies does the facility have on hand (PPE, cleaning/disinfecting supplies, etc.)? Question Title * 6. Have you attempted to pre-order medications and other supplies for residents? Staff Question Title * 7. Are you screening or testing staff for COVID-19? Question Title * 8. Have any staff tested positive? If so, how many/when/current status? Question Title * 9. What is your policy if a staff member shows symptoms of COVID-19? Question Title * 10. Have any staff stopped working due to being at risk of contracting COVID-19? (Including due to being in a high risk group or caring for a person in a high risk group?) Question Title * 11. What are your current staffing levels? Question Title * 12. How many back up staff do you have available? Question Title * 13. What contingency plans do you have if a staff member test positive? Question Title * 14. Are you providing training to staff on COVID-19? If so what training? Residents Question Title * 15. Are you educating residents about COVID-19? If so, how? Question Title * 16. Are you screening or testing residents for COVID-19? Question Title * 17. What is your policy if a resident shows symptoms of COVID-19? Question Title * 18. Have any residents tested positive? If so, how many/when/current status? Question Title * 19. What contingency plans do you have if a resident test positive, including plans for isolation rooms/quarantine rooms? Question Title * 20. Do residents have access to a phone or computer where they can contact friends, family in lieu of visitation, and us if needed? Question Title * 21. What contingency plans do you have in place in case there is a shelter in place order? Question Title * 22. At this time is there anything that you believe would help you better serve your residents? Done