Form CDC 57.147 CDC 57.147 Ventilator Capacity & Supplies

National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

CDC 57.147_COVID-19 form_Ventilator Capacity and Supplies_v2 Final

Ventilator Capacity & Supplies - LCTF Personnel

OMB: 0920-1317

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OMB Approved

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Ventilator Capacity and Supplies



NHSN Facility ID:

CMS Certification Number (CCN):

Facility Name:

*Do you have ventilator dependent unit(s) and/or beds in your facility? □ YES □ NO

If, NO, Skip this form


*Date for which responses are reported: ________/________/________



** For the following questions, please collect data at the same time at least once a week (for example, 7 AM)



_________

MECHANICAL VENTILATORs: Total number available in your facility

_________

MECHANICAL VENTILATORS IN USE: Total number of mechanical ventilators in use for residents who have suspected or laboratory positive COVID-19


Ventilator Supplies

Supply Item

Do you currently have any supply?

Do you have enough for one week?

Ventilator supplies (any, including tubing)

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 5 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).

CDC 57.147 (Front) v.2

*Required for saving

**Form to be completed only if facility has ventilator dependent unit(s) and/or beds

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWattenmaker, Lauren (CDC/DDID/NCEZID/DHQP)
File Modified0000-00-00
File Created2021-05-31

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