Form 0920-1290 COVID-19 Supplies Form

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).