Form 0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte

O MB No. 0920-1296

Exp: 10/31/2020

Version 07/17/2020

Assessment of Healthcare Personnel Exposed to or Infected with SARS-CoV-2

Denominator Form

Instructions

Table A

1. Record the Facility ID

2. Enter the number of HCP who worked at this healthcare facility for at least 1 day during the CALENDAR month:

• Include all HCP who have worked at the facility for at least 1 day during the calendar month being tracked, regardless of clinical responsibility or patient contact. This includes HCP who were on leave for part of the month or were hired or left employment during the month. Working for any number of hours a day counts as 1 day.

• Include both full-time and part-time persons. If a HCP works in 2 or more facilities, each facility should include the HCP in their denominator. Count HCP as individuals rather than full-time equivalents.

• Licensed practitioners who receive a direct paycheck from the reporting facility, or who are owners of the reporting facility, should be counted as employees.

• The HCP categories are mutually exclusive. Each HCP should be counted only once in the denominator.

3. (Optional) Enter the number of COVID-19 patients in the facility during the CALENDAR month:

• These data may be available for some facilities through the National Healthcare Safety Network (NHSN). Many state health departments have access to NHSN data through a group user function

• Report the total number of inpatients with confirmed COVID-19 for the calendar month. Count patients who were hospitalized for any number of days during the month, including patients admitted to the facility before the month being tracked.

Table B (Optional)

1. Record the Facility ID

2. Enter the number of HCP in each occupation category who worked at this healthcare facility for at least 1 day during the CALENDAR month:

• Include all HCP who have worked at the facility for at least 1 day during the calendar month being tracked, regardless of clinical responsibility or patient contact. This includes HCP who were on leave for part of the month or were hired or left employment during the month. Working for any number of hours a day counts as 1 day.

• Include both full-time and part-time persons. If a HCP works in 2 or more facilities, each facility should include the HCP in their denominator. Count HCP as individuals rather than full-time equivalents.

• Count employees and non-employees within each occupation category.

• The HCP categories are mutually exclusive. Each HCP should be counted only once in the denominator.

3. Enter the total number of shifts worked in the facility for each occupation category during the CALENDAR month.

   • Count employees and non-employees within each occupation category.

4. Enter the total number of hours worked in the facility for each occupation category during the CALENDAR month.

   • Count employees and non-employees within each occupation category.

Table A. Record the number of healthcare personnel (HCP) for each category below for the full CALENDAR month (e.g., Jun20 = June 2020).
Facility ID:			Comments:
Month and year				A. Employee HCP	B. Non-Employee HCP			A+B. Total HCP
				Employees (staff on facility payroll)	Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistants	Adult students/ trainees & volunteers	Other contract personnel
May 2020	1a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	1b. (Optional) Number of COVID-19 patients in the facility: _______
Jun 2020	2a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	2b. (Optional) Number of COVID-19 patients in the facility: _______
Jul 2020	3a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	3b. (Optional) Number of COVID-19 patients in the facility: _______
Aug 2020	4a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	4b. (Optional) Number of COVID-19 patients in the facility: _______
Sep 2020	5a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	5b. (Optional) Number of COVID-19 patients in the facility: _______
Oct 2020	6a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	6b. (Optional) Number of COVID-19 patients in the facility: _______
Nov 2020	7a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	7b. (Optional) Number of COVID-19 patients in the facility: _______
Table A (con). Record the number of healthcare personnel (HCP) for each category below for the full CALENDAR month (e.g., Jun20 = June 2020).
Facility ID:		Comments:
Month and year				A. Employee HCP	B. Non-Employee HCP			A+B. Total HCP
				Employees (staff on facility payroll)	Licensed independent practitioners: Physicians, advanced practice nurses, & physician assistants	Adult students/ trainees & volunteers	Other contract personnel
Dec 2020	8a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	8b. (Optional) Number of COVID-19 patients in the facility: _______
Jan 2021	9a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	9b. (Optional) Number of COVID-19 patients in the facility: _______
Feb 2021	10a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	10b. (Optional) Number of COVID-19 patients in the facility: _______
Mar 2021	11a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	11b. (Optional) Number of COVID-19 patients in the facility: _______
Apr 2021	12a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	12b. (Optional) Number of COVID-19 patients in the facility: _______
May 2021	13a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	13b. (Optional) Number of COVID-19 patients in the facility: _______
Jun 2021	14a. Number of HCP who worked at this healthcare facility for at least 1 day during the month
	14b. (Optional) Number of COVID-19 patients in the facility: _______

Table B. Optional detailed denominator data collection form stratified by occupation category. Record the number of healthcare personnel (HCP) AND/OR total shifts AND/OR total hours worked for each occupation category below for the full CALENDAR month (e.g., Jun20 = June 2020).
Facility ID:		Comments:
Month and year	Denominator variable		Physicians (MD, DO)	Nurses (RN, LPN, NP/advanced practice nurses)	Other, specify: __________	Other, specify: __________
May 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Jun 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Jul 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Aug 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Sep 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Oct 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Nov 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month

Table B (con). Optional detailed denominator data collection form stratified by occupation category. Record the number of healthcare personnel (HCP) AND/OR total shifts AND/OR total hours worked for each occupation category below for the full CALENDAR month (e.g., Jun20 = June 2020).
Facility ID:		Comments:
Month and year			Physicians (MD, DO)	Nurses (RN, LPN, NP/advanced practice nurses)	Other, specify: __________	Other, specify: __________
Dec 2020	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Jan 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Feb 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Mar 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Apr 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
May 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month
Jun 2021	Number of HCP who worked at this healthcare facility for at least 1 day during the month
	Total number of shifts worked during the month
	Total number of hours worked during the month

Public reporting burden of this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30329; ATTN: PRA (0920-1296)