0920-1317 CDC 57.1 Resident Impact and Facility Capacity

OMB Approved OMB No. 0920-1317

Exp. Date 1/31/2024 www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Resident Impact and Facility Capacity

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NHSN Facility ID: CMS Certification Number (CCN):

Facility Name: Facility Type:

*Date for which counts/responses are reported: / / *Date Created: / /

Counts should be reported on the correct calendar day and include only the new counts for the calendar day (specifically, since counts were last collected). If the count is zero, a “0” must entered as the response. A blank response is equivalent to missing data. NON-count questions should be answered one calendar day during the reporting week.

Facility Capacity
	**ALL BEDS (enter on first survey only, unless the total bed count has changed)
	*CURRENT CENSUS: Total number of beds that are occupied on the reporting calendar day

Resident Impact for COVID-19 (SARS-CoV-2)
	ADMISSIONS: Number of residents admitted or readmitted from another facility who were previously diagnosed with COVID-19 and continue to require transmission-based precautions. Excludes recovered residents.
	POSITIVE TESTS (previously called “Confirmed”): Number of residents newly positive for COVID-19 based on a viral test result.
	**TEST TYPE: Based on the number of reported Positive Tests, indicate how many were tested using each of the following: **Positive SARS-CoV-2 antigen test only [no other testing performed] **Positive SARS-CoV-2 NAAT (PCR) only [no other testing performed] **±Positive SARS-CoV-2 antigen test and negative SARS-CoV-2 NAAT (PCR) **±Any other combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s) with at least one positive test ± Only include if the two tests were performed within 2 days of each other. Otherwise, count first test only. Important: The total for Test Type should equal the total for Positive Tests
	CALCULATED TOTAL CONFIRMED (not editable by user):
	** VACCINATION STATUS: For positives in each test type category, indicate how many residents received COVID-19 vaccination before the positive test: Positive SARS-CoV-2 antigen test only [no other testing performed]: Not vaccinated with COVID-19 vaccine: Pfizer-BioNTech COVID-19 vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______ Moderna vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______
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-XXXX). CDC 57.144(Front) V.6 (01-2021)
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	Positive SARS-CoV-2 NAAT (PCR) only [no other testing performed]: Not vaccinated with COVID-19 vaccine: Pfizer-BioNTech COVID-19 vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______ Moderna vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______
	Any other combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s) with at least one positive test: Not vaccinated with COVID-19 vaccine: Pfizer-BioNTech COVID-19 vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______ Moderna vaccine: Only 1 dose: ______; Dose 1 and dose 2: ______
	**RE-INFECTIONS: Based on the number of reported Positive Tests, indicate how many met NHSN definition for re-infection. SYMPTOMATIC: Based on the number of reported Re-Infections, indicate how many had signs and/or symptoms consistent with COVID-19. ASYMPTOMATIC: Based on the number of reported Re-Infections, indicate how many did not have signs and/or symptoms consistent with COVID-19.
	TOTAL DEATHS: Number of residents who have died for any reason in the facility or another location: **COVID-19 DEATHS: Based on the number of reported Total Deaths, indicate the number of residents with COVID-19 who died in the facility or another location.
Resident Impact for Non-COVID-19 (SARS-CoV-2) Respiratory Illness
		INFLUENZA: Number of Residents with new influenza (flu).
		RESPIRATORY ILLNESS: Number of Residents with acute respiratory illness symptoms, excluding COVID-19 and/or influenza (flu).
Resident Impact for Co-Infections
		INFLUENZA and COVID-19: Number of residents with a confirmed co-infection with influenza (flu) and SARS-CoV-2 (COVID-19).
		Since the last date of data entry in the Module, has your LTCF performed SARS-CoV-2 (COVID-19) viral testing? □ YES □ NO ** If YES, indicate counts of COVID-19 viral testing that were performed: **POCRESIDENT: Since the last date of data entry in the Module, how many COVID-19 point-of-care tests has the LTCF performed on residents? **POCSTAFF: Since the last date of data entry in the Module, how many COVID-19 point-of-care tests has the LTCF performed on staff and/or facility personnel? **NONPOCRESIDENT: Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on residents? **NONPOCSTAFF: Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on staff and/or facility personnel?

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SARS-CoV-2 TESTING

During the past two weeks, on average how long did it take your LTCF to receive SARS-CoV-2 (COVID-19) viral test results from NON point-of-care tests? (Check one)

• Less than one day

• 1-2 days

• 3-7 days

• More than 7 days

• No testing performed in the past two weeks on residents or staff and/or facility personnel

TESTINGSTAFF: Does the LTCF have the ability to perform or to obtain resources for performing SARS-CoV-2 viral testing (NAAT [PCR] or antigen) on all staff and facility personnel within the next 7 days, if needed?

TESTINGRESIDENT: Does the LTCF have the ability to perform or to obtain resources for performing SARS-CoV-2 viral testing (NAAT [PCR] or antigen) on all current residents within the next 7 days, if needed?