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Basic Contact Information
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| 1. First Name | |
| 2. Last Name | |
| 3. Email | |
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| 4. What is your Specialty?
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| 5. How many physicians are in your practice?
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| 6. Has your practice remained open during the COVID-19 pandemic?
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| 7. Does your practice have enough PPE?
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| 8. If you have experienced a shortage of PPE materials, what do you need?
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| Check all that apply
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| Gloves |
| Gowns |
| Hand Sanitizer |
| N95 Masks |
| Shields |
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| 9. Have you been contacted by the Ohio Department of Health or a local health department regarding distribution of PPE from the state's stockpile?
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| 10. Have you partnered with another clinic to purchase PPE or to meet any of your other needs?
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| 10a. If yes, who?
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| 11. Would you be interested in a group purchase of PPE?
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| 11a. If yes, please provide name and contact info for coordinator.
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| 12. Is your practice providing Telehealth visits?
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| 12a. If yes, what software do you utilize?
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| 12b. If no, are you interested in procuring Telehealth software?
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| 13. If you indicated "Yes" to question 12, what technology do you use?
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| 14. Has your office changed hours of operation since the onset of the pandemic?
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15. What resources or support would you find most useful?
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| Rank 1=Most Important to 5=Least Important
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| General billing guidance | |
| Telehealth billing guidance | |
| Telehealth platform/vendor | |
| Documentation guidance/practice management assistance | |
| Employment Advice (payroll, furlough, leave) | |
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16. What resources or support would you find most useful?
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| Rank 1=Most Important to 5=Least Important
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| Care team workflow, triage, etc. | |
| Temporary housing | |
| Financial support | |
| Personal Protective Equipment | |
| Physician Wellness Support | |
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| 17. Have you applied for a loan by the CARES Act from the Small Business Administration or a private lender?
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| 17a. If yes, is it a forgivable loan?
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| 17b. If yes, what was the range of the loan?
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| 18. Have you been contacted by a private equity firm to purchase your clinic during this pandemic?
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| 18a.If yes, who contacted you? (Will not be shared publicly)
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| 19. Before this pandemic, were you contacted by a private equity firm to purchase your clinic?
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| 19a. If yes, who contacted you? (Will not be shared publicly)
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| 20. How has your practice been financially impacted by changes associated with the pandemic?
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| 21. Please let us know about anything else you'd like to share:
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