All Facilities Details Table
LabID Facility No of Current Resident
 ?

What is your current resident census?

No of Current Staff
 ?

What is your current staff (full-time and part-time) census?

No of Current Contract Employee
 ?

What is your current contract employee census?

No of Agency Staff
 ?

What is your current agency staff census? (I.e. temporary worker hired from an outside agency)

No of Available Beds
 ?

What is the number of beds currently dedicated to your memory care unit (if applicable)?

No of Current Memory Care
 ?

What is your current memory care census?

Has Facility Completed Covid
 ?

Has your facility completed COVID-19 facility-wide testing in the last 30 days? For Staff? If yes, please provide the date.

Date Facility Completed Covid
 ?

Has your facility completed COVID-19 facility-wide testing in the last 30 days? For Staff? If yes, please provide the date.

Has Facility Completed Covid
 ?

Has your facility completed COVID-19 facility-wide testing in the last 30 days? For residents? If yes, please provide the date.

Date Facility Completed Covid
 ?

Has your facility completed COVID-19 facility-wide testing in the last 30 days? For residents? If yes, please provide the date.

Access to a Medical
 ?

Do you have access to a Medical Director, Certified Nurse Practitioner, Nurse Practitioner, Licensed Registered Nurse, Registered Nurse, or Physician Assistant?

No of Surgical/medical masks
 ?

the number of days of personal protective equipment (PPE) supplies your facility currently possess

No of N-95 or equivalent masks
 ?

the number of days of personal protective equipment (PPE) supplies your facility currently possess

No of Face shields/goggles
 ?

the number of days of personal protective equipment (PPE) supplies your facility currently possess

No of Gowns
 ?

the number of days of personal protective equipment (PPE) supplies your facility currently possess

No of Gloves
 ?

the number of days of personal protective equipment (PPE) supplies your facility currently possess

Has Facility Nursing Home
 ?

Is your facility on a campus with a nursing home or attached to a nursing home?

Has Facility Scheduled COVID-19 Testing
 ?

If yes, have you already had/or are scheduled to have your staff and/or resident COVID-19 testing in conjunction with that nursing home?

Scheduled Date of COVID-19 Testing
 ?

If yes, have you already had/or are scheduled to have your staff and/or resident COVID-19 testing in conjunction with that nursing home? If so, please provide the date.

24 Hour Nursing Support
 ?

Does your facility have 24-hour nursing support (RN or LPN)?

Less Than 24 Hour Nursing Support
 ?

If your facility has less than 24-hour nursing support, select your level of support below.