COVID-19 Facilities Survey

Have You Been in a Facility Recently? Do You Know Someone Who Currently Is?
WE WANT TO HEAR FROM YOU!

Disability Rights Nebraska wants to gather information from people about conditions in facilities during the COVID19 pandemic. “Facilities” include nursing homes, regional centers, jails, prisons, group homes, and other residential facilities.

You can help be our eyes and ears to learn what’s happening on the ground. If you’ve recently left a facility—or you are talking to a loved one who is currently in one—we want to know what you can share with us. Please understand we may not contact you about your individual survey submission, but we will use the information to try to ensure we’re protecting the safety and rights of all individuals with disabilities in Nebraska.

You can also complete a PDF of the facilities survey, and send it to amy@drne.org.

Facilities Survey Form

Your Name

Your Email

Your Phone

Name of Person in Facility

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# of Person of Facility (if in Jail or Prison)

Facility Name

Date of Contact with Facility

Observations about Residents (Their Physical Condition, Emotional Condition, Etc.):

Observations about Staff (How Many Were Present, Emotional Condition, Etc.):

Observations about Facility (Cleanliness, Availability of Hygiene Materials, Etc):

Observations Specific to COVID19 (Positive or Negative)

Any Other Observations or Concerns:

By submitting this form, you grant Disability Rights Nebraska permission to contact you regarding the information you have provided.

COVID-19 Facilities Survey

Facilities Survey Form

Lincoln Location

Scottsbluff Location

COVID-19 Facilities Survey

Facilities Survey Form

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