Form 0920-1290 COVID-19 Supplies Form

National Healthcare Safety Network (NHSN) Patient Impact Module for Coronavirus (COVID-19) Surveillance in Healthcare Facilities

Att8_NHSN COVID-19 Supplies Form

COVID-19 Supplies Form - State and Local Health Department

OMB: 0920-1290

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Form Approved

OMB No. 0920-1290

Exp. Date: 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Supplies


Facility ID #: _____________

Summary Census ID #: _________


*Date for which counts are reported: ____/____/________


For the following questions, please collect data at the same time (for example, 7 AM)


Supply Item

On-hand supply

Are you currently re-using the item or implementing extended use?

Are you able to obtain this item?

Ventilator supplies (any, including tubing)

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


N95 masks

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


Other respirators including PAPRs

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


Surgical masks

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


Eye protection including face shields or goggles

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


Gowns (single use)

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


Gloves

Zero days

1-3 days

4-14 days

15 or more days

Yes

No


Yes

No


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)).


CDC estimates the average public reporting burden for this collection of information as 25 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1290).

CDC 57.132 (Front)



* Required for saving

For calculation of the days of supply in stock, we recommend using the Personal Protective Equipment (PPE) Burn Rate Calculator (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/burn-calculator.html).

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWattenmaker, Lauren (CDC/DDID/NCEZID/DHQP)
File Modified0000-00-00
File Created2021-01-14

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