COVID-19 Consumer Evaluation Survey

Consumer Name

Do you have what is necessary to ensure your physical, mental, and emotional health needs are being met at this time?
YesNo

Do you currently feel supported and have all the necessary resources of care being provided to you?
YesNo

Are your Attendants taking all necessary universal precautions (frequent hand washing, social distancing, if possible, staying home if ill, environmental cleaning and disinfecting) when providing care?
YesNo

Do your Attendants have access to personal protective equipment (masks and gloves)?
YesNo

Do you have a backup plan in place in case of an emergency where services would be delayed or halted (alternate caregivers, alternate place to stay, help from family and friends)?
YesNo

Please list any concerns or comments that you may have in the box below: