COVID-19
Module
Long
Term Care Facility: Staff and Personnel Impact
NHSN
Facility ID:
|
CMS
Certification Number (CCN):
|
Facility
Name:
|
*Date
for which responses are reported: ________/________/________
|
For
the following questions, please collect data at the same time at
least
once a week (for example, 7 AM)
_________
|
CONFIRMED:
Staff
and facility personnel with new laboratory-positive COVID-19
|
_________
|
SUSPECTED:
Staff
and facility personnel with new suspected COVID-19 who are being
managed as though they have it.
|
_________
|
COVID-19
DEATHS:
Staff and facility personnel with new suspected or laboratory
positive COVID-19 who died
|
Does
your organization have a shortage of staff and/or personnel?
|
Staffing
Shortage?
|
Staff
and Personnel Groups
|
□ YES
□ NO
|
Nursing
Staff:
registered nurse, licensed practical nurse, vocational nurse
|
□ YES
□ NO
|
Clinical
Staff:
physician, physician assistant, advanced practice nurse
|
□ YES
□ NO
|
Aide:
certified nursing assistant, nurse aide, medication aide, and
medication technician
|
□ YES
□ NO
|
Other
staff or facility personnel,
regardless of clinical responsibility or resident contact not
included in the categories above (for example, environmental
services)
|
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-XXXX).
CDC
57.xxx
(Front)
|
MB
No. 0920-1290