Instruction - Staff and Personnel Impact Form (CDC 57.145) 07MAY2020

Long-term Care Facility Component

Instructions for Completion of the COVID-19 Long-term Care Facility (LTCF): Staff and Personnel Impact Form (CDC 57.145)

Data Field	Instructions for Data Collection
NHSN Facility ID #	The NHSN-assigned facility ID will be auto-entered by the computer.
CMS Certification Number (CCN)	Auto-generated by the computer if the facility has previously entered the CCN number during NHSN registration. See NHSN CCN Guidance document for instructions on how to add a new CCN or edit an entered CCN.
Facility Name	Auto-generated by the computer if the facility has previously entered facility name during registration.
Date for which “staff and personnel Impact” responses are reported	Required. Select the date on the calendar for which the responses are being reported in the NHSN COVID 19-Module.

Important:

While daily reporting will provide the timeliest data to assist with COVID-19 emergency response efforts, retrospective reporting of prior day(s), unless otherwise specified, is encouraged if daily reporting is not feasible. At a minimum, facilities should report data at least once per week.

Data Field	Instructions for Data Collection
CONFIRMED COVID-19 Staff and facility personnel with new laboratory-positive COVID-19	If this is the first time Confirmed COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of staff and facility personnel who have been newly identified with laboratory positive COVID-19 this week. If this is not the first time Confirmed COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of staff and facility personnel who have been newly identified as having a laboratory positive COVID-19 test result since the last date that Confirmed COVID-19 counts (laboratory positive COVID-19 test results) were entered. Note: Include only new laboratory positive test COVID-19 test results among staff and facility personnel since the last time these counts were entered in the Module.  To submit Confirmed counts for staff and facility personnel prior to May 1, 2020 (OPTIONAL): Using the calendar feature, select any calendar date prior to May 1, 2020 and enter the total number of staff and facility personnel with a laboratory-positive COVID-19 test result between January 1, 2020 and April 30, 2020. If these data are not available at the time of data entry, leave blank and revise counts later.   Notes: Please include counts since May 1, 2020 by selecting the appropriate calendar date. Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
SUSPECTED COVID-19 Staff and facility personnel with new suspected COVID-19	If this is the first time Suspected COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of staff and facility personnel who have been or are newly managed as though they have COVID-19, but do not have a laboratory positive COVID-19 test result, this week. If this is not the first time Suspected COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of staff and facility personnel who have been or are newly managed as though they have COVID-19 (but do not have a laboratory positive COVID-19 test result) since the last date that Suspected COVID-19 counts were entered. To submit Suspected counts for staff and facility personnel prior to May 1, 2020 (OPTIONAL): Using the calendar feature, select any calendar date prior to May 1, 2020 and enter the total number of staff and facility personnel who were managed as though they had COVID-19 (but did not have a laboratory positive COVID-19 test result) between January 1, 2020 and April 30, 2020. If these data are not available at the time of data entry, leave blank and revise counts later.   Notes: Please include counts since May 1, 2020 by selecting the appropriate calendar date. Suspected is defined as staff and personnel with signs and symptoms suggestive of COVID-19 as described by CDC’s guidance but do not have a laboratory positive COVID-19 test result. This may include staff and personnel who have not been tested or those with pending test results. It may also include staff and personnel with negative test results but continue to show signs/symptoms suggestive of COVID-19. Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
COVID-19 DEATHS Staff and facility personnel with new suspected or laboratory-positive COVID-19 who died	If this is the first time COVID-19 Death counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of deaths for staff and facility personnel with suspected AND confirmed COVID-19 (laboratory-positive COVID-19 test result) this week. If this is not the first time the COVID-19 Death counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Enter the number of new deaths for staff and facility personnel with suspected AND confirmed COVID-19 (laboratory positive COVID-19) since the last date COVID-19 Death counts were entered. Note: Include only new deaths since the last time these counts were entered in the Module. To submit COVID-19 Death counts for staff and facility personnel prior to May 1, 2020 (OPTIONAL): Using the calendar feature, select any calendar date prior to May 1, 2020 and enter the total number of deaths for staff and facility personnel with suspected AND confirmed COVID-19 (laboratory-positive COVID-19 test result) between January 1, 2020 and April 30, 2020. If these data are not available at the time of data entry, leave blank and revise counts later.   Notes: Please include counts since May 1, 2020 by selecting the appropriate calendar date. Suspected is defined as staff and personnel with signs and symptoms suggestive of COVID-19 as described by CDC’s guidance but do not have a laboratory positive COVID-19 test result. This may include staff and personnel who have not been tested or those with pending test results. It may also include staff and personnel with negative test results but continue to show signs/symptoms suggestive of COVID-19 Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
STAFFING SHORTAGE Does your organization have a shortage of staff and/or personnel? Select “YES” or “NO” for each group. (Select one answer for each group)	On the date responses are reported in in the Module, has your facility identified a shortage of staff and/or facility personnel in any of the following staff and facility personnel groups? Note: Each facility should identify staffing shortages based on their facility needs and internal policies for staffing ratios. Select “YES” for each group in which there is currently a staff shortage OR “NO” for each group in which there is not currently a staff shortage: (Select one answer for each group) Nursing Staff: registered nurse, licensed practical nurse, or vocational nurse. Clinical Staff: physician, physician assistant, or advanced practice nurse. Aide: certified nursing assistant, nurse aide, medication aide, or medication technician. Other staff or facility personnel: that are not included in the above categories, regardless of clinical responsibility or resident contact. These personnel may include, but are not limited to, environmental services, cook, dietary, pharmacists, pharmacy techs, activities director, care givers, wound care, physical therapy, shared staff, etc.

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