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LTCF DHS Needs Assessment

1.Facility Name:(Required.)
2.In which County is your facility located?(Required.)
3.How many Healthcare workers are staffed at your facility? 
4.How many beds does your facility have? 
5.Facility Contact:(Required.)
6.Facility Contact  Title:(Required.)
7.Facility Contact Phone Number:(Required.)
8.Facility Contact email:(Required.)
9.Does your facility have an established respiratory protection plan? 
10.Does your facility have an airborne infection isolation rooms (AIIR)?
11.If yes, how many AIIRs are in your facility? 
12.Does your facility have an adequate supply of personal protective equipment?
Yes
No
N95's
PAPR's
Facial Masks
Gown/Apron
Gloves
Eye Protection
13.If your facility uses/plans to use N95 masks, is your staff fit-tested to wear N95 masks?
14.If your facility uses/plans to use PAPRs, is your staff trained to use PAPRs?
15.Is your staff adequately trained in correctly donning and doffing of PPE?
16.Hand Hygiene Supplies-Does your facility have an adequate amount of hand hygiene supplies (hand soap and alcohol-based hand sanitizer)?
17.Is your staff trained to perform hand hygiene appropriately?
18.Does your facility have a sufficient supply of eye protection (e.g. goggles, face shields)?
19.Is there an immediate need for additional supplies, if so which supplies are needed? Click all that apply:
20.Do you anticipate any material/supply shortages if your facility has a COVID-19 resident(s)?
21.If yes, select the type of supply shortages anticipated:
22.List any other anticipated supply need.
23.Is your facility a member of a healthcare coalition? 
24.Coalition Name
Current Progress,
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