Form 0920-1011 Facility Assessment

Form Approved. OMB No. 0920-1011 Exp. 08/05/2020

SARS-CoV-2 Correctional Facility Assessment

V3 rev 5/06/2020

(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)
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):
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)

Facility Services and Staffing

17. 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

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

________________ (mm/dd/yyyy) 0Unknown

19. 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

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

5. 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:_______________________

6. 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

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

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

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

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

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

21. 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?

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

23. 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

24. 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

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

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

Coronavirus - Inmates

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

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

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

Yes No Unknown

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

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

19. 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

27. 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

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

29. 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

23. 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) __________________________________________________

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

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

Gloves Face Mask Eye protection N95 Gown/Coveralls Unknown

30. 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? _________________________________________

__________________________________________________________________________________

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

Personal Protective Equipment

32. 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

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

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

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

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

    2. If yes, how so? _____________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

36. 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

6. Respondent Name and Title: ____________________________________________________________

7. Interviewer:___________________________ Date Completed: _____________________(MM/DD/YY)

Unit Characteristics

8. Number of detainees currently in the unit: _______

9. Full capacity of unit: ______

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

    1. How many beds per room:_____________________

    2. If dormitory unit, are the sleeping areas: Cells or rooms with a door Cubbies or other enclosure without a door open dormitory Other, specify:______________________

11. Number of floors: ______

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

    1. Toilets: ______

    2. Sinks/handwashing area: _______

    3. Showers:________

Facilities access among detainees in the unit

13. In the past two weeks, identify which facilities/items detainees have had access to and who uses the facilities/items.

	Access Level	Individual vs Shared
Toilets	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 (inside common area)	All the time Restricted None Unknown	Cell only Unit only Multiple units different time Multiple units same time
Recreation Area or yard (outside)	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
Commissary	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
Facility Healthcare Clinic	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

Sanitation

14. In the last two weeks, which of the following items have detainees been provided (check all that apply):

Hand Sanitizer Soap Face Masks None Unknown

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

2. If masks are provided, are they typically being worn:

Always Only outside of cell Only outside of dorm

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

   1. If no, quantity?____________________

1. Could a detainee in this unit wash their hands at all times of the day: Yes No Unknown

Work Units

16. Do any detainees 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 detainees from other units? Yes, at the same time/shift Yes, same areas but different shifts No Unknown

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

Staffing

18. How many staff members are assigned to work in this unit? (extended time in this unit, or working with detainees from this unit) Total _________ (estimate if exact number not known); by category:

    1. Corrections: ________

    2. Environmental/maintenance: _______

    3. Admin: ________

    4. Healthcare: ________

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

19. How many staff members potentially are within 6ft of the detainees for any length of time in this unit for their regular duties? Total _________ (estimate if exact number not known); by category:

    1. Corrections: ________

    2. Environmental/maintenance: _______

    3. Admin: ________

    4. Healthcare: ________

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

Coronavirus

20. 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 Detainees	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

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

________________ (mm/dd/yyyy)

22. When was the most recent positive COVID-19 case identified at this unit (staff or detainee)?

________________ (mm/dd/yyyy)

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