LTCF DHS Needs Assessment Survey

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* 2. In which County is your facility located?

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* 3. How many Healthcare workers are staffed at your facility?

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* 4. How many beds does your facility have?

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* 5. Facility Contact:

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* 6. Facility Contact Title:

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* 7. Facility Contact Phone Number:

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* 8. Facility Contact email:

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* 9. Does your facility have an established respiratory protection plan?

Yes

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* 10. Does your facility have an airborne infection isolation rooms (AIIR)?

Yes

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* 11. If yes, how many AIIRs are in your facility?

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* 12. Does your facility have an adequate supply of personal protective equipment?

	Yes	No
N95's	N95's Yes	N95's No
PAPR's	PAPR's Yes	PAPR's No
Facial Masks	Facial Masks Yes	Facial Masks No
Gown/Apron	Gown/Apron Yes	Gown/Apron No
Gloves	Gloves Yes	Gloves No
Eye Protection	Eye Protection Yes	Eye Protection No

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* 13. If your facility uses/plans to use N95 masks, is your staff fit-tested to wear N95 masks?

Yes

N/A, No Plans to use N95's

Yes, but other fit-tests will be needed

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* 14. If your facility uses/plans to use PAPRs, is your staff trained to use PAPRs?

Yes

Yes, but will require additional training

N/A, No plans to use PAPR's

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* 15. Is your staff adequately trained in correctly donning and doffing of PPE?

Yes

Yes, but will require additional training

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* 16. Hand Hygiene Supplies-Does your facility have an adequate amount of hand hygiene supplies (hand soap and alcohol-based hand sanitizer)?

Yes

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* 17. Is your staff trained to perform hand hygiene appropriately?

Yes

Yes, but additional training is needed.

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* 18. Does your facility have a sufficient supply of eye protection (e.g. goggles, face shields)?

Yes

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* 19. Is there an immediate need for additional supplies, if so which supplies are needed? Click all that apply:

Hand Sanitizer

Hand Soap

Disinfection Solutions

Disinfection Wipes

Gowns

Gloves

Other (please specify)

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* 20. Do you anticipate any material/supply shortages if your facility has a COVID-19 resident(s)?

Yes

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* 21. If yes, select the type of supply shortages anticipated:

N95's

PAPR's

PAPR's Hoods

PAPR Filters

Facial Mask (Procedural/Surgical)

Eye Protection (Googles, Face shield)

Hand Soap

Hand Sanitizer

Cleaning/Disinfection Supplies

Other (please specify)

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* 22. List any other anticipated supply need.

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* 23. Is your facility a member of a healthcare coalition?

Yes

LTCF DHS Needs Assessment

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* 1. Facility Name:

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* 2. In which County is your facility located?

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* 3. How many Healthcare workers are staffed at your facility?

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* 4. How many beds does your facility have?

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* 5. Facility Contact:

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* 6. Facility Contact Title:

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* 7. Facility Contact Phone Number:

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* 8. Facility Contact email:

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* 9. Does your facility have an established respiratory protection plan?

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* 10. Does your facility have an airborne infection isolation rooms (AIIR)?

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* 11. If yes, how many AIIRs are in your facility?

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* 12. Does your facility have an adequate supply of personal protective equipment?

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* 13. If your facility uses/plans to use N95 masks, is your staff fit-tested to wear N95 masks?

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* 14. If your facility uses/plans to use PAPRs, is your staff trained to use PAPRs?

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* 15. Is your staff adequately trained in correctly donning and doffing of PPE?

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* 16. Hand Hygiene Supplies-Does your facility have an adequate amount of hand hygiene supplies (hand soap and alcohol-based hand sanitizer)?

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* 17. Is your staff trained to perform hand hygiene appropriately?

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* 18. Does your facility have a sufficient supply of eye protection (e.g. goggles, face shields)?

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* 19. Is there an immediate need for additional supplies, if so which supplies are needed? Click all that apply:

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* 20. Do you anticipate any material/supply shortages if your facility has a COVID-19 resident(s)?

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* 21. If yes, select the type of supply shortages anticipated:

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* 22. List any other anticipated supply need.

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* 23. Is your facility a member of a healthcare coalition?

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* 24. Coalition Name