COVID Daily Diary

NYSNA encourages all members working during the COVID pandemic to keep a daily log of your experience. Documenting unsafe conditions and inadequate PPE can help protect yourself, our practice, and our patients.

You may use this voluntary daily diary form. Your report is not anonymous due to the nature of this service. However, NYSNA will not use your name or contact info for any report we generate, nor will we share it with your employer or any third party.

We will email you a copy of this form. Please save it for your records.

Your name

Your Email

Mobile Number

Facility

Work Area

Did you treat PUIs or COVID patients today?

Were you provided with adequate PPE?

Adequate PPE for treating COVID-positive patients includes an N95 (or higher level) filtering respirator, of the size and make fit tested for, worn for one patient care session; a liquid-repellent or impermeable gown; gloves, goggles, and face shield.

If your PPE was inadequate, please describe how:

Are you showing symptoms of COVID?

Have you been tested for COVID?

Describe your day. Be sure to include any details that you think are relevant to your personal health and safety and the health of your colleagues and patients.

Do not provide any individually identifiable health information protected under HIPAA in this section.