PPE Survey

Personal Protective Equipment Needs Survey

Do you have needs to help protect your employees and customers? Help us help you keep your customers and employees safe. Even if you have all the items you need, please fill out the survey.

Information collected will be aggregated and not used to identify any business’ individual practices.

By participating in this survey you can provide us with information that can assess the needs for businesses. Based on the information provided, there may be an opportunity for supply support.

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* 1. Business Name

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* 2. Business Zip Code

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* 3. Anticipated Number of Employees working per day.

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* 4. Anticipated Number of Customers per day.

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* 5. Are you currently screening for COVID-19 symptoms including checking temperatures of employees and/or customers?

	Yes	No
Employees	Employees Yes	Employees No
Customers	Customers Yes	Customers No

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* 6. If no, why are you not screening temperatures?

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* 7. Would you screen them if you had access to a thermometer?

Yes

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* 8. Are you having staff self-monitor for COVID-19 symptoms prior to their shift and is this being documented?

Yes

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* 9. What PPE(Personal Protective Equipment) supplies do you have or still need for your business?

	Have	Still Need
Masks (such as surgical)	Masks (such as surgical) Have	Masks (such as surgical) Still Need
Face Coverings (Fabric)	Face Coverings (Fabric) Have	Face Coverings (Fabric) Still Need
Hand Sanitizer	Hand Sanitizer Have	Hand Sanitizer Still Need
Disinfectant Spray (pre-made)	Disinfectant Spray (pre-made) Have	Disinfectant Spray (pre-made) Still Need
Disinfectant Spray (make your own using bleach and water)	Disinfectant Spray (make your own using bleach and water) Have	Disinfectant Spray (make your own using bleach and water) Still Need
Disinfectant Wipes	Disinfectant Wipes Have	Disinfectant Wipes Still Need
No Touch Thermometer	No Touch Thermometer Have	No Touch Thermometer Still Need
Sneeze guards or barriers (Plexiglas or other)	Sneeze guards or barriers (Plexiglas or other) Have	Sneeze guards or barriers (Plexiglas or other) Still Need
Signage re: safe practices, distancing, handwashing, etc.	Signage re: safe practices, distancing, handwashing, etc. Have	Signage re: safe practices, distancing, handwashing, etc. Still Need

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* 10. What is the biggest need your business is facing at this time in regard to supplies, equipment, and/or resources?

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* 11. Are there specific items you need for your business to be open safely?

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* 12. Additional Comments

Please note that the following resources are available to help your businesses safely reopen:

Aspirus Work Well Toolkit
https://www.aspirus.org/business-health

Wood County Health Department Business Toolkit
https://www.co.wood.wi.us/Departments/Health/Doc/Covid/COVID-19%20Business%20Toolkit.pdf

Wisconsin Economic Development – Best Practices to Reopen
https://wedc.org/reopen-guidelines/

Centers for Disease Control and Prevention (CDC)
https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html