Introduction and Contact Information:

Please only provide information as it pertains to the services outlined in this survey for DDD. If your agency provides additional services do your best to estimate the portion of information that applies to these services for DDD members.

Please enter 0 or N/A if you are unable to provide information or if the question is not applicable

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* 2. Please Enter Your Contact Information:

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* 3. Please enter AHCCCS ID:

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* 4. Please enter Employer ID:

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* 5. Does your agency provide nursing supported group home services? (HAN)

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* 6. How many staff worked for your agency on February 25, 2020 and provided services to DDD members? (please provide only numeric data as a response)

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* 7. How many staff worked for your agency on March 25, 2020 and provided services to DDD members? (please provide only numeric data as a response)

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* 8. How many staff worked for your agency on April 25, 2020 and provided services to DDD members? (please provide only numeric data as a response)

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* 9. How many staff worked for your agency on May 25, 2020 and provided services to DDD members? (please provide only numeric data as a response)

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* 10. How many staff worked for your agency on June 25, 2020 and provided services to DDD members? (please provide only numeric data as a response)

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* 11. How many new staff were hired between:

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* 12. How many staff left your agency (laid off, terminated, etc.) between:

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* 13. If there was a reduction in staff between February 1st, 2020 and May 18th., 2020, please answer the following (please provide the number of nurses for each reason):

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* 14. Reason for reduction in staff (please provide a detailed response):

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* 15. Has your agency experienced an increase in demand for nursing supported group home services?

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* 16. Based on your answer to number 15, please provide the following information about changes in services that are delivered by your agency. If there has been a decrease please include a subtraction sign (-10). Please enter “0” if not applicable.

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* 17. How many total staffing hours were scheduled in the following weeks?

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* 18. Has your agency experienced an increase in overtime due to increased demand?

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* 19. Please provide the number of overtime hours paid in each of the following time periods:

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* 20. Has there been a decrease in the number of staff that are dedicated to a specific site home?

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* 21. Please provide the percentage of nurses that were dedicated to a specific site on the following dates:

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* 22. What is the average number of sites a nurse is currently working in per week?

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* 23. Have your agency required front line supervisors or other Management staff to cover vacancies?

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* 24. Please provide the number of front line supervisors or other Management staff that covered vacancies on the following dates:

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* 25. Does your agency have enough nursing  staff to meet member needs as of July 4th, 2020?

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* 26. How many vacant nursing staff hours are you trying to fill weekly? (Please provide only numeric data as a response)

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* 27. Does your agency have enough CNA/DCW staff to meet member needs as of July 4th, 2020?

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* 28. Approximately how many hours per week do you need to fill for CNA? (please provide only numeric data as a response)

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* 29. Approximately how many hours per week do you need to fill for DCW? (Please provide only numeric data as a response)

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* 30. Have you seen an increase in Paid or Unpaid Time Off due to Covid-19? 

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* 31. If Yes, please provide the number of hours per month vacated with Paid Time Off due to COVID-19?

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* 32. If Yes, please provide the number of hours per month vacated with Unpaid Time Off due to COVID-19?

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* 33. If Time Off due to COVID-19 is Paid, what is the total cost of those hours?

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