MaineMDA LTC COVID follow up VACCINATION SURVEY (facility identifying information will remain confidential)

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* 1. Where is your facility located? (county)

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* 2. Role of individual completing the survey?

Infection Preventionist

DON (Director of Nursing)

ADON (Asst. Director of Nursing)

Administrator

Other (please specify)

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* 3. What type of facility are you?

Nursing Facility (NF) only

Skilled Nursing Facility (SNF/NF)

Elder Care Community (NF/SNF/AL/IL)

Assisted Living Facility (AL)

Assisted Living and independent Living facility (AL/IL)

PNMI level I-IV residential care

AL & NF

Other (please specify)

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* 4. Are you planning to provide additional vaccination clinics?

Yes, we have clinic(s) scheduled

No future clinics are planned

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* 5. What type of vaccine did your facility use to vaccinate residents and staff?

Pfizer vaccine

Moderna vaccine

J&J

Pfizer & Moderna

Pfizer & J&J

Moderna & J&J

We didn’t have vaccination clinics

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* 6. What is your Resident Covid vaccination rate (round to the closest number)?

100% of residents vaccinated

90-99% of residents vaccinated

80-89% of residents vaccinated

70-79% of residents vaccinated

60-69% of residents vaccinated

50-59% of residents vaccinated

Less than 50% of residents vaccinated

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* 7. Staff vaccination consent rate (round to the closest number)

100% of staff vaccinated

90-99% of staff vaccinated

80-89% of staff vaccinated

70-79% of staff vaccinated

60-69% of staff vaccinated

50-59% of staff vaccinated

Less than 50% of staff vaccinated

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* 8. How are you vaccinating new residents and staff?

On site vaccination on a weekly basis

On site vaccination as needed

Refer to outside community clinics (without providing transportation for residents)

Refer to outside community clinics (transportation provided for residents)

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* 9. Are you aware of the CDC classification of new Covid variants as potentially airborne

Yes

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* 10. What PPE does your unvaccinated staff use at this time?

N95 mask

Surgical Mask

N95 & Shield

Surgical Mask & Shield

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* 11. Do you have a different PPE policy for unvaccinated staff?

Yes

No, they have same PPE requirement as vaccinated staff

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* 12. If staffing shortages were not an issue, would you consider mandating Covid vaccination for new staff?

Yes

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* 13. If staffing wasn’t an issue would you consider mandating Covid vaccination for existing staff?

Yes

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* 14. Have you begun reporting your vaccination rate through NHSN or the state reporting mechanism?

Yes, NHSN

Yes, State Reporting

Yes, Both

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* 15. If you experienced a Covid outbreaks since your vaccine clinic, was it related to unvaccinated staff?

Yes

We didn’t have post vaccination Covid outbreaks