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Primary Care PPE Survey - Distributed April 29, 2020
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1.
Please identify your region:
(Required.)
Central
Central West
Mississauga Halton
North Simcoe Muskoka
I don't know
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2.
Please provide a contact person and practice address so that we can follow-up with you. The contact person may be different from the person completing this survey.
(Required.)
First name (do not include Dr.)
Last name
Role (MD, NP, Allied Health, Office Manager)
Street address
City / town
Postal code
CPSO# (if MD)
Email (direct email for contact)
Clinic phone number
Alternate phone number (to ensure we can reach you should we receive PPE for primary care)
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3.
Please identify your practice type:
(Required.)
Fee-For-Service
Comprehensive Care Model
Family Health Group
Family Health Network
Family Health Organization
Family Health Organization - Family Health Team
Community Health Centre
Nurse Practitioner-Led Clinic
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4.
I am responding on behalf of the following total number of physicians/nurse practitioners at our site:
(Required.)
N/A
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
20+
5.
Collectively, I/we care for the following number of patients (ex. total practice size):
0 - 2,000
2,001 - 4,000
4,001 - 6,000
6,001 - 8,000
8,001 - 10,000
10,001 - 12,000
12,001 - 14,000
14,001 - 16,000
16,001 - 18,000
18,001 - 20,000
20,001 - 22,000
22,001 - 24,000
24,001 - 26,000
26,001+
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6.
Is your family medicine or NP clinic open or closed? (The answer to this question will not be shared with the CPSO).
(Required.)
Open for in-person visits
Open for both in-person and virtual visits
Open for virtual visits only (e.g., video or phone)
Closed (not seeing or responding to patient inquiries)
Other (please specify)
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7.
Are you seeing symptomatic patients in-person?
(Note: symptoms are not solely respiratory in nature but include typical and atypical symptoms for COVID-19 such as: cough, fever, fatigue, sputum, shortness of breath, muscle aches, sore throat, headache, chills, nasal congestion, nausea or vomiting, diarrhea, exacerbation of chronic conditions, etc.)
(Required.)
Yes
No
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8.
Are you considering closing your practice in the next two weeks to in-person visits?
(Required.)
Yes - Due to PPE shortage
Yes - Due to my age or medical co-morbidities
Yes - Other
No
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9.
How much of the following PPE items do you have left? (At your current rate of use, based on COVID-19 guidance and best practices for virtual and in-person clinics)
(Required.)
Surgical / procedure mask
Isolation gown
Gloves
Eye protection (goggles or face shield)
PPE supply
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
*
10.
How much of the following environmental cleaning items do you have left? (At your current rate of use, based on COVID-19 guidance and best practices for virtual and in-person clinics)
(Required.)
Disinfectant wipes
Hand sanitizer
Cleaning supply
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
Out of supply
One week supply
Two weeks supply
Three weeks supply
Four weeks or more
I don't know
Current Progress,
0 of 10 answered
