COVID Vaccination Planning Survey: Healthcare Workforce & Clinics
This survey is the second in a series meant to support Humboldt County Public Health in mapping the distribution plans for the initial doses of COVID-19 vaccine (Phase 1A).
This survey should be filled out by a lead administrator or person who is responsible for your workplace. The email you give here will be utilized for future correspondence regarding vaccination planning. Thank you for your participation in this survey.
* Required
Do you work for a healthcare organization or are you a private caregiver to a medically vulnerable individual?
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Health care organization
Private caregiver
Other:
Q1. What is the name of your organization? Please write n/a if you are a private caregiver.
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Your answer
Q2. What is the name and title of the person completing this survey?
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Your answer
Q2. What is the job title of the person completing this survey?
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Your answer
Q3. What is the email address of the person completing this survey? This survey is meant to be completed by the person responsible for distributing information within your organization.
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Your answer
Q4. What is the phone number of the person completing this survey?
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Your answer
Q5. How many highest risk (for COVID-19) healthcare workers work in your facility? Highest risk= front line clinical staff who care for patients in high risk settings or for patients with unknown COVID status (e.g. ED, ICU, urgent care, respiratory therapists, anesthesiologists, etc.)
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Your answer
Q6. How many high risk healthcare workers work in your facility? High risk= front line clinical staff who provide direct patient care and support staff with risk of exposure to bodily fluids.
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Your answer
Q7. How many moderate risk healthcare workers work in your facility? Moderate risk= staff who have indirect or limited patient contact (e.g. food services, medical records, front desk staff)
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Your answer
Q8. How many low risk healthcare workers work in your facility? Low risk= administrative support with no routine patient contact.
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Your answer
Q9. How many total healthcare staff work at your facility? (This answer should be equal to the sum of the previous four questions.)
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Your answer
Q10. With existing internal resources, please estimate the number of staff that could be vaccinated in your facility one working day.
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Your answer
Q11. Do you have a mechanism in place to ensure your employees receive the second doses of COVID vaccine in the recommended timeframe?
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Yes
No
Q12. Is your clinic or organization able to accommodate closed (healthcare workers only) vaccination clinics for local healthcare personnel and first responders who are not employed by you or a current patient?
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Yes
No
Q13. Any additional comments regarding vaccination administration, clinic planning or distribution?
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Your answer
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