Supplemental digital content for Baker ML, Peesay T, Rooney A, Sayyed A, Syed Z. An Auxiliary Medical Education: Learning Through the Evolution of a Medical Student-Founded Not-for-Profit Organization in Response to the COVED-19 Era Personal Protective Equipment Shortage. Acad Med.
Supplemental Digital Appendix 1
Sample Needs Assessment Questionnaire, Developed by Medical Supply Drive for Collection and Distribution of Donated Personal Protective Equipment During the COVID-19 Pandemic
Needs Assessment Questionnaire (Example)
Facility Information
1. Name of the facility: ______________________________
2. Address of the facility: _______________________________________________
City: ___________________ State: _________________ Zip Code: ___________
3. Is it a healthcare facility? Yes / No
1. If yes, how many patient beds at the facility? __________
2. If not, what type of facility? ________________
2. Does the facility work with COVID-19+ individuals? Yes / No
Supply Needs
3. Does the facility accept opened but unused boxes of donations? Yes / No 4. How many weeks’ worth of supplies does the facility have left? __________
5. Which items is the facility most in need of for the next month? Number the top three items needed, in order of importance (i.e. 1 = most needed, 3 = least needed):
Copyright © the Association of American Medical Colleges. Unauthorized reproduction is prohibited. 1
Supplemental digital content for Baker ML, Peesay T, Rooney A, Sayyed A, Syed Z. An Auxiliary Medical Education: Learning Through the Evolution of a Medical Student-Founded Not-for-Profit Organization in Response to the COVED-19 Era Personal Protective Equipment Shortage. Acad Med.
Masks
__ Surgical Masks __ N95 Masks __ KN95 __ KF94 __ FFP2 __ FFP3
__ Cloth Masks
Gloves
__ Non-Latex Gloves __ Latex Gloves __ Food-Grade Gloves
Disinfectants __ Hand Sanitizer __ Clorox Wipes __ Bleach
Eye Protection __ Face Shields __ Goggles
Surgical Gowns __ AAMI Level 1 __ AAMI Level 2 __ AAMI Level 3 __ AAMI Level 4
Disinfectants __ Hand Sanitizer __ Clorox Wipes __ Bleach
Other
__ Shoe Covers __ Surgical Cap
8. Of the supplies chosen, what quantities are needed to last one month at the facility?
(1) _______________
(2) _______________
(3) _______________
PPE Turnover at the Facility
9. How many employees need to be equipped with PPE? ________________
10. Is the facility currently reusing the PPE requested?
(1) Yes / No (2) Yes / No (3) Yes / No
Copyright © the Association of American Medical Colleges. Unauthorized reproduction is prohibited. 2
Supplemental digital content for Baker ML, Peesay T, Rooney A, Sayyed A, Syed Z. An Auxiliary Medical Education: Learning Through the Evolution of a Medical Student-Founded Not-for-Profit Organization in Response to the COVED-19 Era Personal Protective Equipment Shortage. Acad Med.
11. For the items being requested, how many uses per item before it is discarded?
(1) ________________
(2) ________________
(3) ________________
Purchasing Ability
12. Does the facility have the ability to purchase items? Yes / No a. If yes, what is the estimated budget? $___________
13. Address for delivery (if different from facility address above):
14. Best date and time for delivery: ____/____/_______ (mm/dd/yyyy) _____:_____AM / PM 15. Contact information for delivery:
a. Name: __________________________
b. Email: __________________________
c. Phone Number: (____) _____ - ______
16. Are any of the staff open with being in social media posts to help promote MSD? We ensure anonymity but love sharing progress with our donors and supporters! Yes / No
a. If yes, check which information they are comfortable sharing:
__ Photos __ Facility Name __ Staff Name __ Donation type
Copyright © the Association of American Medical Colleges. Unauthorized reproduction is prohibited. 3
