Form 0920-1011 Facility Survey

Form Approved. OMB No. 0920-1011 Exp. 0 8/02/2020

SARS-CoV-2 Correctional Facility Assessment

V2 rev 4/20/2020

(Correctional Facility Transmission Investigation)

Facility Survey

1. Interviewer:___________________________ Date Completed: _____________________

2. Facility Name:________________________________________________________________________

3. County: __________________________ State: ___________________ ZIP Code: __________________

4. Entity that owns the facility:____________________________________________________

5. Entity that operates the facility:____________________________________________________

6. Level of security (check all that apply): Minimum Medium High

7. Respondent Name: ____________________________________________________________

8. Respondent Title: ____________________________________________________________

Staffing

9. Total number of staff, by category

Category	Employees (n)	Contractors (n)	Total (n)
Corrections
Administrative staff
Kitchen staff
Maintenance staff
Healthcare
Doctors
Physician assistants
Nurse practitioners
Nurses
Pharmacy
Laboratory staff
Dental staff
Radiology
Administrative staff
Sum

Incarcerated Population and Capacity

10. What were the characteristics of the incarcerated population in January 2020 vs. the incarcerated population now?

    	January 2020	Currently
    Inmate population (estimated average):
    Proportion low security (estimated):	%	%
    Proportion medium security (estimated):	%	%
    Proportion high security (estimated):	%	%
    Average daily intakes:
    Average daily transfers to this facility:
    Average daily transfers to other facilities:
    Average daily releases to community:

11. Maximum occupant capacity per original facility design: _____________________

12. Maximum occupants at full capacity (as currently functioning): _____________________

13. Have general visitation been restricted or suspended? Yes No Unknown

1. If yes, when did this go into effect? ­­­­­­­­­­­­­­____________________ (mm/dd/yyyy)

14. Have transfers to/from other prisons been suspended? Yes No Unknown

1. If yes, when did this go into effect? ­­­­­­­­­­­­­­____________________ (mm/dd/yyyy)

15. Have transfers to/from other jails been suspended? Yes No Unknown

1. If yes, when did this go into effect? ­­­­­­­­­­­­­­____________________ (mm/dd/yyyy)

16. Have restrictions been put in place with regard to in person legal appointments/attorney access? Yes No Unknown

4. If yes, when did this go into effect? ­­­­­­­­­­­­­­____________________ (mm/dd/yyyy)

Health Facilities

17. How many hours per day is the health clinic currently staffed? 8 hours 16 hours 24 hours Other:____ Unknown

18. Number of individuals that can currently be treated at the clinic per day? ________

19. Number of inpatient beds?______________

20. Services currently provided:

    Mental health care	Laboratory and diagnostic care
    Dental Care	Substance abuse treatment
    Preventative care	Nurse sick call
    Nursing treatments	Other, specify:_____________
    Medical provider visits	Other, specify:_____________

21. If inmates need additional care during the response, are they sent to a healthcare facility? Yes No Unknown

5. If yes, specify: ______________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________

Facility Services and Staffing

22. Who provided the following services in January 2020 and who are they currently performed by?

Service	January 2020	Currently
Kitchen	Inmates Contractor Jail Staff	Inmates Contractor Jail Staff
Cleaning	Inmates Contractor Jail Staff	Inmates Contractor Jail Staff
Education	Inmates Contractor Jail Staff	Inmates Contractor Jail Staff
Laundry	Inmates Contractor Jail Staff	Inmates Contractor Jail Staff
Transportation	Contractor Jail Staff	Contractor Jail Staff
Groundskeeping	Inmates Contractor Jail Staff	Inmates Contractor Jail Staff

Coronavirus - General

23. When was the first positive COVID-19 case identified at your facility (staff or inmate)?

________________ (mm/dd/yyyy) 0Unknown

24. How many suspected (individuals with fever, cough, or shortness of breath) or confirmed COVID-19 cases have been identified at your facility since January 2020? (Write “unknown” if value not known).

	Among Inmates	Among Staff
Suspected COVID-19 Cases (PUIs)
Confirmed COVID-19 Cases
Suspected Hospitalized COVID-19 Cases (PUIs)
Confirmed Hospitalized COVID-19 Cases
Any death
COVID-19-related Deaths

25. Are confirmed COVID-19 cases currently being reported to the local health department? Yes No Unknown

26. Are you aware of CDC guidance for managing COVID-19 in correctional facilities? Yes No

1. If yes, have you incorporated the guidance in your protocols/processes? Yes No Unknown

   1. If yes, when were these measures adopted? ­­­­­­­­­­­­­__________________ (mm/dd/yyyy)

27. Are staff or inmates tested for coronavirus? Yes No Unknown

7. If yes, what test is being used? (check all that apply) OP Swab (PCR) NP Swab (PCR) Blood (serology) Unknown If known, specify name of test:_______________________

8. Who is currently being tested? (check all that apply) Symptomatic inmates Symptomatic staff Inmates exposed to a laboratory-confirmed COVID-19 case Staff exposed to a laboratory-confirmed COVID-19 case New inmates to the facility Random screening for at-risk inmates Random screening for at-risk staff All staff All inmates Upon staff request Upon inmate request Other, specify:________________ Unknown

9. Is testing done on individuals once, or repeatedly over time? Repeatedly Once

10. Where are test results being processed? Public Health Lab Commercial lab Hospital lab Other, specify_________________ Unknown

11. What is the average turnaround time from the time of testing to the result? _____________ (days)Unknown

12. How many tests can be processed a day? __________________

Coronavirus – Staff (Write “unknown” if value or date not known).

28. Are staff checked daily for symptoms prior to shift start? Yes No Unknown

1. If yes, when were these measures implemented? ­­­­­­­­­­­­­__________________ (mm/dd/yyyy)

2. What is the threshold for a fever? ________F

3. What happens if a staff member has symptoms?

29. Does a staff member have to disclose if they had a positive test? Yes No Unknown

30. If a staff member has a positive test, are they temporarily furloughed? Yes No Unknown

    1. If yes, for how long are they furloughed? ________________________

    2. Are they paid during the furlough? Yes No Unknown

31. Would it be possible to have staff assigned to work in a single inmate housing unit (or limit the amount of buildings they work in or work assignments they supervise)? Yes No Unknown

16. If yes, is this currently being done? Yes No Unknown

17. If yes, when were these measures implemented? ­­­­­­­­­­­­­__________________ (mm/dd/yyyy)

Coronavirus - Inmates

32. Are all inmates checked daily for symptoms of coronavirus? Yes No Unknown

1. If yes, when did this start? _____________________ (mm/dd/yyyy)

33. Are all new inmate intakes quarantined for 14 days before entering the facility general population?

Yes No Unknown

19. If yes, when did this start? ______________________ (mm/dd/yyyy)

20. Are they quarantined: Individually As a cohort Other, specify:_______________

21. Are quarantined inmates checked daily for symptoms of coronavirus? Yes No Unknown

    1. If yes, when did this start? _____________________ (mm/dd/yyyy)

    2. Is their temperature checked? Yes No Unknown

34. Are inmates who have laboratory-confirmed COVID-19 isolated from other inmates? Yes No Unknown

1. If yes, how many laboratory-confirmed COVID-19 cases could you isolate before isolation capacity would be exhausted? ____________________

2. How are these individuals isolated: Individually As a cohort Other, specify:_____________

3. Are confirmed COVID-19 cases separated from suspected cases (PUIs) as well? Yes No Unknown

35. Are inmates who are suspected cases (PUIs) isolated from other inmates? Yes No Unknown

36. When would an inmate without symptoms be quarantined for 14 days? (check all that apply)

If exposed / had contact with a confirmed COVID-19 case If exposed / had contact with a suspected COVID-19 case

25. How is exposure or contact with a COVID-19 case defined? (e.g., any close contact, part of the same unit, sleeps in same room) __________________________________________________

26. How many times per day are these individuals monitored for symptoms? _______ x per day

27. What PPE is worn by the people who perform these checks? Check all that apply.

Gloves Face Mask Eye protection N95 Gown/Coveralls Unknown

37. Are inmates screened for COVID-19 symptoms before being released from the facility? Yes No Unknown

    1. What happens if they have COVID-19 symptoms? _________________________________________

__________________________________________________________________________________

38. Is the release of inmates who are under isolation or quarantine coordinated with the regional public health department? Yes No Unknown

Personal Protective Equipment

39. What level of PPE is worn/has available to each level of staff? Check all that apply.

    Correctional officers	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Transport Services	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Legal	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Administrative	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Doctors	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Nurses	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Pharmacy	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Clinic Admin	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Maintenance	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Kitchen	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown
    Dental staff	Gloves Face Mask Eye protection N95 Gown/Coveralls	Unknown

40. Are all staff who have direct contact with confirmed cases wearing N95 respirators, eye protection, gloves, and a gown? Yes No Unknown

41. Are all staff who have direct contact with suspected cases (PUIs) wearing N95 respirators, eye protection, gloves, and a gown? Yes No Unknown

42. Have cleaning and disinfection protocols changed since January 2020? Yes No Unknown

    1. If yes, when?________________________________ (mm/dd/yyyy)

    2. If yes, how so? _____________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

43. Are inmates given cleaning supplies to clean their cells? Yes No Unknown

Unit Survey [Complete this survey for each unit of the facility assessed.]

1. Facility Name:________________________________________________________________________

2. Unit Name: __________________________________________________________________________

3. Location (building, floor, room, etc):______________________________________________________

4. Level of security (check all that apply): Minimal Medium High

5. Respondent Name and Title: ____________________________________________________________

6. Interviewer:___________________________ Date Completed: _____________________

Unit Characteristics

7. Number of inmates currently in the unit: _______

8. Full capacity of unit: ______

9. Unit type: Single cells Dormitory (communal) housing

   1. How many beds per room:_____________________

10. Number of floors: ______

Facilities

11. Identify which facilities/items inmates currently have access to and who uses the facilities.

	Access Level	Individual vs Shared
Lavatory	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Showers	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Dining Area	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Recreation Area	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Phone Access	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Computer Access	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Common area with tables/chairs	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Games	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Television	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Library	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Other:____________	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time

12. How many of the following items are present within the unit:

    1. Toilets: ______

    2. Sinks/handwashing area: _______

    3. Showers:________

13. In the last two weeks, have inmates in this unit:

Exposure	Answer
…been to the dormitory yard? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to a common area to eat? (if food delivered to cell, select no) If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…used the common area phone? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to the recreation area? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…used the common area computer? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been transported off of the jail campus (e.g. medical or legal appointments)? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…had a visitor from outside the jail who you were able to meet in person with? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…visited the clinic? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to the library? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to the education center? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to the commissary? If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown
…been to another part of the facility? (Specify:___________________) If yes, days per week?_________ (1-14 days) On those days, how many hours per day? _______ (hours)	Yes No Unknown

Infrastructure

14. What type of heating does this unit have? Forced air Radiator Other, specify:_________ Unknown

15. Does this unit have windows? Yes No Unknown

16. Does this unit have windows that open? Yes No Unknown

17. Does this unit have air conditioning? Yes No Unknown

18. Since the index COVID-19 case developed symptoms on [insert date of symptom onset, only ask questions relative to those above]:

    1. Has air conditioning been used? Yes No Unknown

    2. Have any windows been opened for ventilation? Yes No Unknown

    3. Has any other form of ventilation (e.g. ceiling fans or portable fans) been used? Yes No Unknown

Sanitation

19. Which of the following items have inmates been provided: Hand Sanitizer Soap Face Masks Unknown

    1. If masks are provided, how often are they replaced or washed?______________________

    2. If soap is provided, is it unlimited? Yes No Unknown

       1. If no, quantity?____________________

20. Could an inmate in this unit wash their hands at all times of the day: Yes No Unknown

Work Units

21. Do any inmates in this unit perform duties or services (e.g. work at the facility)? Yes No Unknown

    1. If yes, do they work in, Their unit only Other common areas Both

       1. [if in other common areas] Do they work with inmates from other units? Yes, at the same time/shift Yes, same areas but different shifts No Unknown

22. Which jobs are performed by inmates in this unit? Kitchen Library Education Laundry Groundskeeping Unknown Other, specify: __________________________

Staffing

23. How many staff members are assigned to work in this unit? (extended time in this unit, or working with inmates from this unit) _________ (estimate if exact number not known)

by category,

1. Corrections: ________

2. Environmental/maintenance: _______

3. Admin: ________

4. Healthcare: ________

5. Other:_______________ (specify job class:___________________________________)

1. How many staff members potentially are within 6ft of the inmates for any length of time in this unit for their regular duties? _________ (estimate if exact number not known)

by category,

1. Corrections: ________

2. Environmental/maintenance: _______

3. Admin: ________

4. Healthcare: ________

5. Other:_______________ (specify job class:___________________________________)

Coronavirus

25. How many suspected (individuals with fever, cough, or shortness of breath) or confirmed COVID-19 cases have been identified in this unit since January 2020? (Write “unknown” if value not known).

    	Among Inmates	Among Staff
    Suspected COVID-19 Cases (PUI)
    Confirmed COVID-19 Cases
    Suspected Hospitalized COVID-19 Cases (PUI)
    Confirmed Hospitalized COVID-19 Cases
    Any Death
    COVID-19-related Deaths

26. When was the first positive COVID-19 case identified at this unit (staff or inmate)?

________________ (mm/dd/yyyy)

Version 2.0 April 20, 2020 12

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