The code block below illustrates how one might use # and // as comments in your logic and calculations.

# Text can be put here to explain what the logic/calculation does and why.
if ([field1] = '1' and [field2] > 7,

	// This comment can explain what the next line does.
	[score] * [factor],

	// Return '0' if the condition is False.
	0
)

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LTC Booster Vaccination Baseline Assessment

Fellow Nursing Home and Assisted Living facilities,

As mentioned by our State and Federal partners, we are all preparing for our booster vaccination roll out. To ensure a smooth and efficient process, please take a few minutes to answer the following questions.

The State will use this information to assist with addressing gaps and to maintain an updated level of awareness of your current capacity.

Thank you for ALL you and your staff continue to do throughout this pandemic! It is truly an honor responding alongside you all!

MDH Long-term Care Battle Plan Team

health.seocltc@state.mn.us

datetime

M-D-Y H:M

Name of person completing information

* must provide value

Email of person completing information

* must provide value

What is the facility HFID number?

* must provide value

Facility Type

* must provide value

Skilled Nursing Facilities:
Search either by your licensed name, HFID, or address
****Begin typing or click on down arrow

Assistant Living Facilities:
Search either by your licensed name, HFID, or address
****Begin typing or click on down arrow
****Patiently wait a few seconds as it is uploading thousands of records

Facility Name

Facility Address

Type of facility
Please provide license type or other details outlining the type of facility you are operating.

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As we work towards identifying how our Skilled Nursing and Assisted Living facilities will ensure their residents and staff have access to booster vaccinations, please answer the questions below.

Please reference the Vaccine Provider Models for Continuing COVID-19 Vaccination Efforts in Minnesota Long-term Care Facilities for detailed information on each of the five models: https://www.health.state.mn.us/diseases/coronavirus/hcp/ltcvaxmodel.pdf

Please select the model through which you are currently meeting the COVID-19 vaccination needs of your residents and staff:

* must provide value

Model 1: Full service on-site vaccination at LTC facilities

Model 2: Full service off-site vaccination

Model 3: Hybrid of on-site and off-site vaccination

Model 4: Partial service on-site vaccination at LTC facilities

Model 5: LTC facility staff-led on-site vaccination

Unknown - Haven't determined which is our best-fit model.

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Have you begun discussions with your vaccine provider about booster shots?

* must provide value

Yes

Scheduled to connect soon

Do not have a vaccine provider

We are utilizing staff-led on site vaccination

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How confident are you that your vaccine provider will be able to serve your booster shot needs for residents and staff?

* must provide value

Extremely confident

Somewhat confident

Not Confident

Unsure/Unknown

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Vaccine provider name

If you are utilizing staff-led on-site vaccination, please indicate 'Staff Led' in this field.

* must provide value

Vaccine provider address

Vaccine provider city

Vaccine provider zipcode

Have you scheduled a booster vaccine clinic?

* must provide value

Yes

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If yes, what is the date your booster vaccine clinic is scheduled for?

If no, leave blank.

D-M-Y

To best gauge the potential need for assistance in effectively providing booster shots to your residents and staff, please select all that apply.

* must provide value

Assistance with registering as a vaccine provider

Assistance with finding a vaccine provider

Assistance with additional staff to administer vaccine. (NOTE: The facility ONLY needs staff as they have all other aspects covered.)

Assistance with accessing a roster of vaccination status for residents

Other, please specify in the comment box below

Please share additional concerns, barriers, or gaps hindering you from effectively administering or offering booster shots for your residents and staff.

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Booster incentive: Please share, if any, booster incentive ideas you are either considering for your residents and staff.

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Have you compiled a roster of vaccine status for your residents?

* must provide value

Yes

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If yes, did you verify vaccination status using MIIC?

* must provide value

Have you compiled a roster of vaccine status for your staff?

* must provide value

Yes

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You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.