Pandemic Preparedness Survey for Clinics

Pandemic Preparedness Survey for Clinics — Form Fields

This healthcare template includes 12 fields. Healthcare facility administrators complete a pandemic preparedness assessment covering staff, supplies, and protocols. Free to customize and use on ZenBuild.

• Facility Name (text, required)
• Administrator Name (text, required)
• Contact Email (email, required)
• Facility Type (dropdown selection, required) — options: Primary Care Clinic, Urgent Care, Hospital, Specialty Clinic, Community Health Center
• Number of Clinical Staff (number, required)
• PPE Supply Level (dropdown selection, required) — options: Well Stocked (3+ months), Adequate (1–3 months), Low (Under 1 month), Critical - Shortage
• Infection Control Protocol in Place? (dropdown selection, required) — options: Yes - Fully Updated, Yes - Needs Update, No
• Surge Capacity Plan Documented? (dropdown selection, required) — options: Yes, In Progress, No
• Telehealth infrastructure ready (checkboxes, optional)
• Staff pandemic training completed (checkboxes, optional)
• Patient isolation areas designated (checkboxes, optional)
• Gaps or concerns in pandemic readiness (long text, optional)