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* 1. Facility Name:

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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?

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

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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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