COVID-19 Patient Impact Module Form

Form Approved

OMB No. 0920-XXXX

Exp. Date: XX/XX/2020

www.cdc.gov/nhsn

COVID-19

Patient Impact and Hospital Capacity Module

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

_________	HOSPITALIZED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19
_________	HOSPITALIZED and VENTILATED: Patients currently hospitalized in an inpatient bed who have suspected or confirmed COVID-19 and are on a mechanical ventilator
_________	HOSPITAL ONSET: Patients currently hospitalized in an inpatient bed with onset of suspected or confirmed COVID-19 fourteen or more days after hospital admission due to a condition other than COVID-19
_________	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
_________	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
_________	DEATHS: Patients with suspected or confirmed COVID-19 who died in the hospital, ED, or any overflow location on the date for which you are reporting

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

	ALL HOSPITAL BEDS: total number of all inpatient and outpatient beds in your hospital, including all staffed, licensed, overflow, and surge or expansion beds used for inpatients and for outpatients (includes ICU beds)
_________	*HOSPITAL INPATIENT BEDS: total number of staffed inpatient beds in your hospital including all licensed, overflow, and surge or expansion beds used for inpatients (includes ICU beds)
_________	HOSPITAL INPATIENT BED OCCUPANCY: total number of staffed inpatient beds that are occupied
_________	ICU BEDS: Total number of staffed inpatient ICU beds
_________	ICU BED OCCUPANCY: total number of staffed inpatient ICU beds that are occupied
_________	MECHANICAL VENTILATORS: Total number of ventilators available
_________	MECHANICAL VENTILATORS IN USE: total number of ventilators in use

*Required for saving

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).