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https://app.smartsheet.com/b/form/fa2d7abfb102490b9d2622a2ba490744
Submission Tags: falconsandbox
Submission: On December 19 via api from US — Scanned from DE
Submission Tags: falconsandbox
Submission: On December 19 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_Facility Name" data-client-type="dropdown" id="Or7090m" class="css-u3yn36 ef83ajd0"><label for="select_input_Facility Name" id="5e269cb1-1ec3-48ea-a027-075d02cd954d"
data-client-id="label_Facility Name" class="css-1xl1v40 ekxsfat0">Facility Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<p id="description_select_input_Facility_Name" class="css-1jo9ly9 e5k3c9p0">Please select your facility name from the dropdown. If your facility name is not listed or the facility name has changed, please select "OTHER" from the dropdown menu.
</p>
<div class="css-t8xanh-container">
<div class="css-kf2egt-control react-select__control">
<div class="css-11ksah1 react-select__value-container">
<div class="css-1i5h0xy-placeholder react-select__placeholder">Select</div>
<div class="css-1g6gooi">
<div class="react-select__input" style="display: inline-block;"><input autocapitalize="none" autocomplete="off" autocorrect="off" id="select_input_Facility Name" spellcheck="false" tabindex="0" type="text" aria-label="Select"
aria-labelledby="5e269cb1-1ec3-48ea-a027-075d02cd954d" value="" aria-describedby="description_select_input_Facility_Name"
style="box-sizing: content-box; width: 2px; background: 0px center; border: 0px; font-size: inherit; opacity: 1; outline: 0px; padding: 0px; color: inherit;">
<div
style="position: absolute; top: 0px; left: 0px; visibility: hidden; height: 0px; overflow: scroll; white-space: pre; font-size: 13px; font-family: Arial; font-weight: 400; font-style: normal; letter-spacing: normal; text-transform: none;">
</div>
</div>
</div>
</div>
<div class="css-1wy0on6 react-select__indicators"><span class="css-9lpq22-indicatorSeparator react-select__indicator-separator"></span><span style="margin-right: 6px;"><svg data-client-id="caret_icon" width="16px" height="16px"
viewBox="0 0 16 16" version="1.1" role="img" xmlns="http://www.w3.org/2000/svg">
<title>Caret Icon</title>
<desc>Caret symbol</desc>
<g stroke="none" stroke-width="1" fill="none" fill-rule="evenodd">
<g fill="#161616">
<path
d="M8.38951287,9.81740951 C8.3743818,9.83527284 8.35811596,9.85207547 8.34082332,9.86770589 C8.12569934,10.0621513 7.79871352,10.0396329 7.61048004,9.81740951 L5.12806062,6.88673235 C5.04550447,6.78926879 5,6.66416424 5,6.53465776 C5,6.23937443 5.23172713,6 5.51757703,6 L10.4824159,6 C10.607785,6 10.7288928,6.04700617 10.8232427,6.13228679 C11.0383667,6.32673222 11.0601658,6.664509 10.8719323,6.88673235 L8.38951287,9.81740951 Z">
</path>
</g>
</g>
</svg></span></div>
</div>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Facility License Number" data-client-type="text" id="1bPOprk" class="css-1e3khfm ef83ajd0"><label for="text_box_Facility License Number" data-client-id="label_Facility License Number"
class="css-1xl1v40 ekxsfat0">Facility License Number<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Facility License Number" data-client-id="text_box_Facility License Number" data-client-type="NUMERIC" type="number" name="1bPOprk"
maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<fieldset data-client-id="container_Is your facility name not listed, or has your facility name changed?" data-client-type="radio" data-client-align="vertical" id="NrJ3LwN" class="css-110bzo0 etth7i50">
<legend data-client-id="label_Is your facility name not listed, or has your facility name changed?" class="css-1yfbzum etth7i52">Is your facility name not listed, or has your facility name changed?<span data-client-id="required_indicator"
class="css-mfmuai etth7i53">*</span></legend>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Facility Name Not Listed" tabindex="-1" data-client-value="Facility Name Not Listed"
data-client-id="radio_Is your facility name not listed, or has your facility name changed?" type="radio" title="Facility Name Not Listed" name="NrJ3LwN" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Facility Name Not
Listed</span></label></div>
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Facility Name Changed" tabindex="-1" data-client-value="Facility Name Changed"
data-client-id="radio_Is your facility name not listed, or has your facility name changed?" type="radio" title="Facility Name Changed" name="NrJ3LwN" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Facility Name
Changed</span></label></div>
</div>
</fieldset>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Previous Facility Name" data-client-type="text" id="Or75klG" class="css-1e3khfm ef83ajd0"><label for="text_box_Previous Facility Name" data-client-id="label_Previous Facility Name"
class="css-1xl1v40 ekxsfat0">Previous Facility Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Previous Facility Name" data-client-id="text_box_Previous Facility Name" data-client-type="" name="Or75klG" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_New Facility Name" data-client-type="text" id="ZlJ7l8P" class="css-1e3khfm ef83ajd0"><label for="text_box_New Facility Name" data-client-id="label_New Facility Name" class="css-1xl1v40 ekxsfat0">New Facility
Name<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_New Facility Name" data-client-id="text_box_New Facility Name" data-client-type="" name="ZlJ7l8P" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Facility Name Not Listed" data-client-type="text" id="3eGLXdg" class="css-1e3khfm ef83ajd0"><label for="text_box_Facility Name Not Listed" data-client-id="label_Facility Name Not Listed"
class="css-1xl1v40 ekxsfat0">Facility Name Not Listed<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Facility Name Not Listed" data-client-id="text_box_Facility Name Not Listed" data-client-type="" name="3eGLXdg" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Address" data-client-type="text" id="lPrkjjZ" class="css-1e3khfm ef83ajd0"><label for="text_box_Address" data-client-id="label_Address" class="css-1xl1v40 ekxsfat0">Address<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Address" data-client-id="text_box_Address" data-client-type="" name="lPrkjjZ" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_City" data-client-type="text" id="bNwdJJM" class="css-1e3khfm ef83ajd0"><label for="text_box_City" data-client-id="label_City" class="css-1xl1v40 ekxsfat0">City<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_City" data-client-id="text_box_City" data-client-type="" name="bNwdJJM" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Zip" data-client-type="text" id="DQ8vYY7" class="css-1e3khfm ef83ajd0"><label for="text_box_Zip" data-client-id="label_Zip" class="css-1xl1v40 ekxsfat0">Zip<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_Zip" data-client-id="text_box_Zip" data-client-type="NUMERIC" type="number" name="DQ8vYY7" maxlength="4000" class="css-1p0590h e1407lhe0"
value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_County" data-client-type="text" id="OqR177L" class="css-1e3khfm ef83ajd0"><label for="text_box_County" data-client-id="label_County" class="css-1xl1v40 ekxsfat0">County<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="-1" id="text_box_County" data-client-id="text_box_County" data-client-type="" name="OqR177L" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Point of Contact" data-client-type="text" id="j5Qk1NG" class="css-1e3khfm ef83ajd0"><label for="text_box_Point of Contact" data-client-id="label_Point of Contact" class="css-1xl1v40 ekxsfat0">Point of Contact<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Point of Contact" data-client-id="text_box_Point of Contact" data-client-type="" name="j5Qk1NG" maxlength="4000" class="css-1p0590h e1407lhe0" value="">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Point of Contact Phone Number" data-client-type="text" id="vMRwErm" class="css-1e3khfm ef83ajd0"><label for="text_box_Point of Contact Phone Number" data-client-id="label_Point of Contact Phone Number"
class="css-1xl1v40 ekxsfat0">Point of Contact Phone Number<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;">
<div class=" react-tel-input" style="height: 35px; width: 40px;">
<div class="special-label">Phone</div><input class=" form-control" placeholder="1 (702) 123-4567" type="tel" name="vMRwErm" aria-hidden="true" aria-label="phone picker" value="+1" style="display: none;">
<div class=" flag-dropdown">
<div class="selected-flag" title="United States: + 1" tabindex="0" role="button" aria-haspopup="listbox">
<div class="flag us">
<div class="arrow"></div>
</div>
</div>
</div>
</div><input aria-invalid="false" tabindex="0" id="text_box_Point of Contact Phone Number" data-client-id="text_box_Point of Contact Phone Number" data-client-type="PHONE" type="text" value="+1 (___) ___-____" inputmode="numeric">
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Point of Contact Email" data-client-type="text" id="bqJ7bMb" class="css-1e3khfm ef83ajd0"><label for="text_box_Point of Contact Email" data-client-id="label_Point of Contact Email" class="css-1xl1v40 ekxsfat0">Point
of Contact Email<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Point of Contact Email" data-client-id="text_box_Point of Contact Email" data-client-type="EMAIL" name="bqJ7bMb" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Vaccinations" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Vaccinations" class="css-1ogntkt e1vg1njp1">Vaccinations</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<fieldset data-client-id="container_Has your facility scheduled booster or additional dose clinics?" data-client-type="radio" data-client-align="vertical" id="Gl3P0PL" class="css-110bzo0 etth7i50">
<legend data-client-id="label_Has your facility scheduled booster or additional dose clinics?" class="css-1yfbzum etth7i52">Has your facility scheduled booster or additional dose clinics?<span data-client-id="required_indicator"
class="css-mfmuai etth7i53">*</span></legend>
<div class="css-ml5vzx etth7i51">
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="Yes" tabindex="0" data-client-value="Yes" data-client-id="radio_Has your facility scheduled booster or additional dose clinics?" type="radio" title="Yes"
name="Gl3P0PL" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">Yes</span></label></div>
<div class="css-1la7ftu etth7i55"><label class="css-1fg467d etth7i56"><input aria-label="No" tabindex="0" data-client-value="No" data-client-id="radio_Has your facility scheduled booster or additional dose clinics?" type="radio" title="No"
name="Gl3P0PL" class="css-10i6ipn etth7i57"><span class="css-1pu7ejh etth7i58">No</span></label></div>
</div>
</fieldset>
</div>
<div class="css-tkslta e1tmc1mx0">
<div data-client-id="container_Date of Booster Vaccination Clinic" data-client-type="date" id="ErwppWM" class="css-gbq6lm ef83ajd0"><label for="date_Date of Booster Vaccination Clinic" data-client-id="label_Date of Booster Vaccination Clinic"
class="css-1xl1v40 ekxsfat0">Date of Booster Vaccination Clinic<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div class="css-1f92r3b"><input data-client-id="date_Date of Booster Vaccination Clinic" id="date_Date of Booster Vaccination Clinic" aria-label="Date of Booster Vaccination Clinic" tabindex="-1" name="Date of Booster Vaccination Clinic"
maxlength="100" class="css-1dpiipj epidubd0" value=""><button tabindex="-1" type="button" aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img"
width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
<rect width="13" height="13" x="2" y="2" fill="#005EE0" rx="1"></rect>
<path fill="#FFF"
d="M11.648 12h-.96V8.38c-.351.328-.765.571-1.241.728v-.871c.25-.082.523-.238.817-.467.294-.229.495-.496.605-.801h.779V12zm-6.385-1.33l.93-.112c.03.237.11.418.24.543.129.125.286.188.47.188a.648.648 0 0 0 .502-.226c.135-.15.203-.353.203-.608 0-.241-.065-.433-.195-.574a.621.621 0 0 0-.475-.212c-.123 0-.27.024-.44.072l.105-.783c.26.007.458-.05.595-.17a.602.602 0 0 0 .205-.476.545.545 0 0 0-.15-.403.54.54 0 0 0-.4-.15.579.579 0 0 0-.42.17c-.117.114-.188.28-.213.5l-.885-.151c.061-.303.154-.545.279-.726.124-.182.297-.324.52-.428.221-.103.47-.155.746-.155.472 0 .85.15 1.135.45.234.247.352.525.352.835 0 .44-.24.79-.721 1.053.287.061.516.199.688.413a1.2 1.2 0 0 1 .258.776c0 .44-.16.815-.482 1.125-.32.31-.72.464-1.2.464-.453 0-.829-.13-1.127-.39a1.538 1.538 0 0 1-.52-1.025zM11 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2zM6 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2z">
</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Staff" data-client-type="text" id="0DEdXbq" class="css-1e3khfm ef83ajd0"><label for="text_box_Total # of Staff" data-client-id="label_Total # of Staff" class="css-1xl1v40 ekxsfat0">Total # of Staff<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Staff" data-client-id="text_box_Total # of Staff" data-client-type="NUMERIC" type="number" name="0DEdXbq" maxlength="4000"
class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Staff Fully Vaccinated" data-client-type="text" id="965b5rG" class="css-1e3khfm ef83ajd0"><label for="text_box_Total # of Staff Fully Vaccinated" data-client-id="label_Total # of Staff Fully Vaccinated"
class="css-1xl1v40 ekxsfat0">Total # of Staff Fully Vaccinated<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Staff Fully Vaccinated" data-client-id="text_box_Total # of Staff Fully Vaccinated" data-client-type="NUMERIC" type="number"
name="965b5rG" maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Staff Who Have Received Booster or Additional Dose" data-client-type="text" id="vMRj0DG" class="css-1e3khfm ef83ajd0"><label for="text_box_Total # of Staff Who Have Received Booster or Additional Dose"
data-client-id="label_Total # of Staff Who Have Received Booster or Additional Dose" class="css-1xl1v40 ekxsfat0">Total # of Staff Who Have Received Booster or Additional Dose<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Staff Who Have Received Booster or Additional Dose"
data-client-id="text_box_Total # of Staff Who Have Received Booster or Additional Dose" data-client-type="NUMERIC" type="number" name="vMRj0DG" maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Residents" data-client-type="text" id="X8JYMeM" class="css-1e3khfm ef83ajd0"><label for="text_box_Total # of Residents" data-client-id="label_Total # of Residents" class="css-1xl1v40 ekxsfat0">Total # of
Residents<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Residents" data-client-id="text_box_Total # of Residents" data-client-type="NUMERIC" type="number" name="X8JYMeM"
maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Residents Fully Vaccinated" data-client-type="text" id="dGrjm0O" class="css-1e3khfm ef83ajd0"><label for="text_box_Total # of Residents Fully Vaccinated"
data-client-id="label_Total # of Residents Fully Vaccinated" class="css-1xl1v40 ekxsfat0">Total # of Residents Fully Vaccinated<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Residents Fully Vaccinated" data-client-id="text_box_Total # of Residents Fully Vaccinated" data-client-type="NUMERIC"
type="number" name="dGrjm0O" maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Total # of Residents Who Have Received Booster or Additional Dose" data-client-type="text" id="965NE5M" class="css-1e3khfm ef83ajd0"><label
for="text_box_Total # of Residents Who Have Received Booster or Additional Dose" data-client-id="label_Total # of Residents Who Have Received Booster or Additional Dose" class="css-1xl1v40 ekxsfat0">Total # of Residents Who Have Received
Booster or Additional Dose<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex; width: 193px;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Total # of Residents Who Have Received Booster or Additional Dose"
data-client-id="text_box_Total # of Residents Who Have Received Booster or Additional Dose" data-client-type="NUMERIC" type="number" name="965NE5M" maxlength="4000" class="css-1p0590h e1407lhe0" value="" style="width: 300px;"></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Testing" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Testing" class="css-1ogntkt e1vg1njp1">Testing</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div role="application" title="" data-client-id="container_What testing requirement was your facility operating under last week?" data-client-type="dropdown" id="1b7oZlL" class="css-u3yn36 ef83ajd0"><label
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LTC COVID-19 VACCINATION AND TESTING REPORTING The Illinois Department of Public Health is requiring all licensed long-term care facilities that are not required to report COVID-19 vaccination and testing aggregate data into the National Healthcare Safety Network (NHSN) to report this data to the department weekly utilizing this form. For answers to frequently asked questions, please visit this link: https://dph.illinois.gov/covid19/community-guidance/long-term-care/ltc-reporting-faq.html . Facility Name* Please select your facility name from the dropdown. If your facility name is not listed or the facility name has changed, please select "OTHER" from the dropdown menu. Select Caret IconCaret symbol Facility License Number* Is your facility name not listed, or has your facility name changed?* Facility Name Not Listed Facility Name Changed Previous Facility Name* New Facility Name* Facility Name Not Listed* Address* City* Zip* County* Point of Contact* Point of Contact Phone Number* Phone Point of Contact Email* VACCINATIONS Has your facility scheduled booster or additional dose clinics?* Yes No Date of Booster Vaccination Clinic* Calendar IconCalendar Total # of Staff* Total # of Staff Fully Vaccinated* Total # of Staff Who Have Received Booster or Additional Dose* Total # of Residents* Total # of Residents Fully Vaccinated* Total # of Residents Who Have Received Booster or Additional Dose* TESTING What testing requirement was your facility operating under last week?* Select Caret IconCaret symbol Total # of Staff Tested in the Last Week* Total # of Residents Tested in the Last Week* Total # of COVID-19 Positive Staff in the Last Week?* Total # of COVID-19 Positive Residents in the Last Week?* -------------------------------------------------------------------------------- Send me a copy of my responses Submit Powered by Smartsheet Modern Logo On Light Privacy Notice|Report Abuse