* required for saving
| Tracking #:
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Facility ID:
| *Survey Year:
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*National Provider #:
| *CMS certification #:
| State Provider #:
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Facility Characteristics
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*Ownership (check one):
□ For profit □ Not for profit, including church □ Government □ Veteran’s Affairs
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*Certification (check one):
□ Dual Medicare/Medicaid □ Medicare only □ Medicaid only □ State only
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*Affiliation (check one): □ Independent, free-standing □ Independent, continuing care retirement community □ Multi-facility organization (chain) □ Hospital system, attached □ Hospital system, free-standing
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In the previous 12 months, □ No LTCF or not operational in this survey year *Average daily census: _______ *Number of Short stay residents (<90 days): _______ *Number of Long-stay residents (>90 days): _______ Average Length of Stay for Short stay residents (<90 days): _______ Average Length of Stay for Long-stay residents (>90 days): _______
*Number of New Admissions: _________
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* Total Number of Beds: _________ *Indicate the percentage of beds represented by the following service types: (must sum to 100%) a. Long-term General Nursing: __________ b. Long-term Dementia: __________ c. Skilled nursing/Short-term (subacute) rehabilitation: __________ d. Long-term psychiatric (non dementia): __________ e. Ventilator: __________ f. Bariatric: __________ g. Other: __________
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Infection Control Practices
*Number of FTE dedicated to infection control activity in facility: __________ a. Total hours per week performing surveillance: __________ b. Total hours per week for infection control activities other than surveillance: __________ c. Total hours per week performing other duties, not related to infection control: __________
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Continued >>
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Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.137 (Front) v6.4
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