0920-1296 Assessment of Healthcare Personnel Exposed to or Infecte

O MB No. 0920-1296

Exp: 10/31/2020

Version 09/17/2020

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

Denominator Form

Table A (Required for all facilities that participate in Influenza Vaccination Summary reporting to the National Healthcare Safety Network’s Healthcare Personnel Vaccination Module)

Table A. Record the number of healthcare personnel (HCP) for each category below based on Influenza Vaccination Summary reported to the National Healthcare Safety Network’s Healthcare Personnel Vaccination Module. Data should be reported for the 2019-2020 influenza season and, when available, the 2020-2021 influenza season.
Years:	Comments:
Facility ID	Number of HCP who worked at the healthcare facility for at least 1 day between October 1 and March 31 of the report years (e.g., 2019–2020)
	Employee HCP	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

Table B (Optional but strongly encouraged)

Instruction

1. Record facility ID; sites should report one table per facility.

2. Enter the number of COVID-19 patients and/or the number of COVID-19-patient-days 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 in column A. Count patients who were hospitalized for any number of days during the month, including patients admitted to the facility before the month being tracked.

• Report the total number of COVID-19-patient-days for the calendar month in column B. Count the number of COVID-19 patients each day from the first day to the last day of the month and add them up to get the total number of COVID-19-patient-days for the month.

Table B: Record the number of COVID patients hospitalized in the facility and/or the number of COVID-patient-days for the full CALENDAR month
Facility ID: _________	Comment:
Month and year	Number of COVID-19 patients	Number of COVID-19-patient-days
May 2020
Jun 2020
Jul 2020
Aug 2020
Sep 2020
Oct 2020
Nov 2020
Dec 2020
Jan 2021
Feb 2021
Mar 2021
Apr 2021
May 2021
Jun 2021
Jul 2021
Aug 2021
Sep 2021
Oct 2021
Nov 2021
Dec 2021

Table C (Optional)

Instruction

1. Record the Facility ID; sites should report one table per facility

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.

Table C. 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
Number of HCP who worked at this healthcare facility for at least 1 day during the month	May 2020
	Jun 2020
	Jul 2020
	Aug 2020
	Sep 2020
	Oct 2020
	Nov 2020
	Dec 2020
	Jan 2021
	Feb 2021
	Mar 2021
	Apr 2021
	May 2021
	Jun 2021
	Jul 2021
	Aug 2021
	Sep 2021
	Oct 2021
	Nov 2021
	Dec 2021

Table D (Optional)

Instruction

1. Record the Facility ID; sites should report one table per facility.

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 D. 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
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
Jul 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
Aug 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
Sep 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
Oct 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
Nov 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
Dec 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

Table E (Optional). Customizable form for reporting of HCP denominator data.

Instruction

1. Record the Facility ID; sites should report one table per facility.

2. Enter the number of HCP who worked at this healthcare facility for at least 1 day during the time period specified. The total no. of HCP and/or up to 4 separate categories of HCP can be recorded,.

• 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 time period specified. 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 during the time period specified.

4. Enter the total number of hours worked in the facility during the time period specified.

Table E. Optional denominator data collection form. Record the number of healthcare personnel (HCP) AND/OR total shifts AND/OR total hours worked for each occupation category below for the specified time frame. The total number of HCP and/or up to 4 categories of HCP may be reported, below.
Facility ID:	Comments:
Date range		Total	Category 1: __________	Category 2: ____________	Category 3: ____________	Category 4: ____________
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours
___ / ___/ ___ through ___ / ___/ ___	Number of HCP who worked at this healthcare facility for at least 1 day
	Total number of shifts
	Total number of hours