Form 0920-1290 COVID-19 Healthcare Worker Form

Form Approved

OMB No. 0920-1290

Exp. Date: 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Healthcare Worker Staffing

Facility ID #: _____________

Summary Census ID #: _________

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

Does your organization have an urgent shortage or will have an impending shortage within a week?

CRITICAL STAFFING SHORTAGE TODAY: Does your organization consider that it has a critical staffing shortage in this group today?	CRITICAL STAFFING SHORTAGE WITHIN A WEEK: Does your organization anticipate that it will have a critical staffing shortage in this group within one week?	Healthcare worker staff groups
[Yes/No]	[Yes/No]	Environmental services
[Yes/No]	[Yes/No]	Nurses: registered nurses and licensed practical nurses
[Yes/No]	[Yes/No]	Respiratory therapists
[Yes/No]	[Yes/No]	Pharmacists and pharmacy techs
[Yes/No]	[Yes/No]	Physicians: attending physicians, fellows
[Yes/No]	[Yes/No]	Other licensed independent practitioners: advanced practice nurses, physician assistants
[Yes/No]	[Yes/No]	Temporary physicians, nurses, respiratory therapists, and pharmacists (“per diems,” “travelers,” retired, or other seasonal or intermittently contracted persons)
[Yes/No] If yes, specify: What are the other groups not included in the above for which your facility has a critical staffing shortage?	[Yes/No] If yes, specify: What are the other groups not included in the above for which your facility anticipates a critical staffing shortage?	Other HCP† (Persons who work in the facility, regardless of clinical responsibility or patient contact not included in categories above.) †Healthcare Personnel (HCP) is the plural of healthcare worker
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 57.131 (Front)

*Required for saving