Name *

First Name

Last Name

Phone *

(###)

###

####

Has your facility returned to pre-pandemic guidelines regarding PPE, including one N95 mask per patient and having a 90-day supply of PPE? *

Please check all that apply

Yes

No, my facility is still operating according to crisis conservation guidelines

Other

Which of the following best describes staffing at your facility?

We have been adequately staffed

We were short-staffed during the surge, but staffing ratios have returned to pre-pandemic levels and we are now adequately staffed

We were short-staffed during the surge, and staffing ratios have returned to pre-pandemic levels, which are inadequate

Other

Are you or your co-workers floating and receiving training for new assignments?

Yes, we are floating and receiving training

Yes, we are floating but NOT receiving training

No

Other

Are you receiving crisis, bonus, or hazard pay?

Yes

No

Other

Are you having trouble accessing COVID testing or taking time off when you suspect you may have a COVID-related illness? *

Yes

No

Overall, how would you rate your employer’s pandemic planning (including its plan to protect employees) & communication with staff?

Excellent

Good

Poor

Very Poor

Other