COVID-19 Preparedness Survey, Food Providers

If any of this information changes once this survey is completed, please update in real time by emailing info@partnersforhome.org

Question Title

* 1. Your Information

Organization Name

Name and Type of Facility

How many unique client interactions do you have each day?

What percentage of your clients are over the age of 60?

How many intake staff do you have?

Name of person completing this form (first and last)

Title

Email Address

Phone Number

Question Title

* 2. Does your agency have N95 Face Masks?

Yes

Question Title

* 3. Does your agency have other face masks?

Yes

Question Title

* 4. Does your agency have liquid hand soap?

Yes

Question Title

* 5. Does your agency have hand sanitizer (ethanol-based, at least 60%)?

Yes

Question Title

* 6. Does your agency have paper hand towels?

Yes

Question Title

* 7. Does your agency have facial tissues?

Yes

Question Title

* 8. Does your agency have gloves in a variety of sizes?

Yes

Question Title

* 9. Does your agency have thermometers?

Yes

Question Title

* 10. Does your agency have cleaning products for hard surfaces (viricide or bleach)?

Yes

Question Title

* 11. Does your agency currently have sufficient cleaning supplies for increased cleaning frequencies of office equipment and outreach vehicles? If not, what resources do you need in order to increase cleaning frequency?

Question Title

* 12. Is your agency continuing to provide food? If so, when?

Question Title

* 13. If your agency is continuing to provide onsite food, does it have the capacity to stagger meal times to avoid large gatherings of people?

Yes

N/A

Question Title

* 14. Does your agency currently have sufficient hand washing space?

Yes

Question Title

* 15. If you answered no to question 14, please explain your need:

Question Title

* 16. Have service offerings changed at your agency and if so, please share what services you are offering and when?

Question Title

* 17. Is your agency actively using the symptom screening tool with all clients?

Yes