COVID-19 Survey for Senior Care/LTC Facilities - Survey Form

1. Which best describes your organization?
Choose one.
- Senior Care Provider
- Vendor, Consultant, Government, or Other

9. Have any of the staff had to be quarantined in the last 30 days due to exposure with a suspected or confirmed COVID-19 resident?
- Yes
- No
- Not Sure

13-A. What percentage of your employees have been tested for COVID-19?
- 90 -100%
- 50 - 90%
- 25 - 50%
- 1 -25%
- None
13-B. What best describes your employee testing (choose one)
- Every week
- Every two weeks
- When symptoms emerge or have potentially come in contact with COVID-19

14-A. What percentage of your residents have been tested for COVID-19?
- 90 -100%
- 50 - 90%
- 25 - 50%
- 1 -25%
- None
14-B. What best describes your resident testing (choose one)
- Every week
- Every two weeks
- When symptoms emerge or have potentially come in contact with COVID-19

16. What will need upgrading/replacing/enhancement before the end of the year?

	Not a Priority	Low Priority	Medium Priority	High Priority	Highest Priority
Infection prevention systems and supplies
Workforce management software (including better employee communication tools)
Family communication platforms
Food services
Screening/security tools
Renovation, design, and furniture to better accommodate social distancing
Telehealth systems
Medical equipment and supplies
Pharmacy Services and software
Training

17. Has your facility achieved a new normal that allows for family visitation (with proper screening) and a return to group activities including dining (with some additional social distancing incorporated)?
Please indicate whether you agree.
- Yes
- No, but expect to by October 1
- No and not sure when we will

20. What is the number 1 priority now?

Please select the priority for each option. If your top priority is not shown, please include it as "other" and describe your top priority below.

	Not Priority	Low Priority	Medium Priority	High Priority	Highest Priority
Funding to cover unanticipated expenses
Testing for all employees and residents
More effective screening for those entering the facility
Better infection control processes
Better systems for treating residents with suspected or confirmed COVID-19 infection
Safely reopening with resident activities/communal dining/visitation)
Other, please specify below

21. What type of information/guidance would help your facility to navigate the coming months?

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COVID-19 Survey for Senior Care/LTC Facilities – Survey Form