00920-1290 COVID-19 Patient Impact Module Form 29MAY2020

Form Approved

OMB No. 0920-1290

Exp. Date: 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Patient Impact and Hospital Capacity Pathway

Facility ID #: _____________

Summary Census ID #: _________

*Date for which patient impact and hospital capacity counts are reported: ____/____/________

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

Section 1: Patient Impact Data Elements

_________	PREVIOUS DAY’S ADMISSIONS WITH CONFIRMED COVID-19: New patients admitted to an inpatient bed who had confirmed COVID-19 at the time of admission
_________	PREVIOUS DAY’S ADMISSIONS WITH SUSPECTED COVID-19: New patients admitted to an inpatient bed who had suspected COVID-19 at the time of admission
_________ _________	PREVIOUS DAY’S NEW HOSPITAL ONSET: Current inpatients hospitalized for a condition other than COVID-19 with onset of suspected or confirmed COVID-19 on the previous day and the previous day is fourteen or more days since admission Number of Previous Day’s New Hospital Onset with Confirmed COVID-19 (subset)
_________ _________	HOSPITALIZED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19 Number of Hospitalized with Confirmed COVID-19 (subset)
_________ _________	HOSPITALIZED and VENTILATED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19 and are on a mechanical ventilator Number of Hospitalized and Ventilated with Confirmed COVID-19 (subset)
_________ _________	HOSPITALIZED and ICU: Patients currently hospitalized in an inpatient ICU bed who have suspected or confirmed COVID-19 Number of Hospitalized and ICU with Confirmed COVID-19 (subset)
_________ _________	HOSPITAL ONSET: Total current inpatients with onset of suspected or confirmed COVID-19 fourteen or more days after admission for a condition other than COVID-19 Number of Hospital Onset with Confirmed COVID-19 (subset)
_________ _________	ED/OVERFLOW: Patients with suspected or confirmed COVID-19 who currently are in the Emergency Department (ED) or any overflow location awaiting an inpatient bed Number of ED/Overflow with Confirmed COVID-19 (subset)
_________ _________	ED/OVERFLOW and VENTILATED: Patients with suspected or confirmed COVID-19 who currently are in the ED or any overflow location awaiting an inpatient bed and on a mechanical ventilator Number of ED/Overflow and Ventilated with Confirmed COVID-19 (subset)
_________ _________	PREVIOUS DAY’S DEATHS: Patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location on the previous calendar day Number of Previous Day’s Deaths with Confirmed COVID-19 (subset)

Section 2: Hospital Bed/ Intensive Care Unit (ICU)/ Ventilator Capacity Data Elements

_________	ALL HOSPITAL BEDS: Total number of all staffed inpatient and outpatient beds in your hospital, including all overflow and surge/expansion beds used for inpatients and for outpatients (includes all ICU beds)
_________	*HOSPITAL INPATIENT BEDS: Total number of staffed inpatient beds in your hospital including all overflow and surge/ expansion beds used for inpatients (includes all ICU beds)
_________	HOSPITAL INPATIENT BED OCCUPANCY: Total number of staffed inpatient beds that are occupied
_________ _________	ICU BEDS: Total number of staffed inpatient ICU beds Number of ICU Beds that are Neonatal Beds (subset)
_________ _________	ICU BED OCCUPANCY: Total number of staffed inpatient ICU beds that are occupied Number of Occupied ICU Beds that are Neonatal Beds (subset)
_________	MECHANICAL VENTILATORS: Total number of ventilators available
_________	MECHANICAL VENTILATORS IN USE: Total number of ventilators in use
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 40 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 57.130 (Front)

*Required for saving

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