0920-1317 Staff and Personnel COVID-19 Event Form 22SEP2021

OMB Approved

OMB No. 0920-1317

Exp. Date 01/31/2024

www.cdc.gov/nhsn

Staff and Personnel

*Facility ID:	Event #:
*Staff ID:
* Name: First: Middle: Last:
*Gender: F M Other	*Date of Birth: ___/___/____
Collecting race and ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups. *Ethnicity (specify): □ Hispanic or Latino □ Not Hispanic or Latino □ Declined to respond □ Unknown	Collecting race and ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups. *Race (specify): □ American Indian/Alaska Native □ Asian □ Black or African American □ Native Hawaiian/Other Pacific Islander □ White □ Declined to respond □ Unknown
Event Details
*Event Type: COVID-19		*Date of Event: __/__/____

COVID-19 Event Form

*TEST TYPE: The staff member was determined to have a newly positive SARS-CoV-2 viral test result using which of the following testing options (select only one): _____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 select if the two tests were performed within 2 calendar days from initial test (test date is calendar day one). Otherwise, select the first test performed only.
*RE-INFECTIONS: Respond to questions based on the current COVID-19 event (SARS-COV-2 infection). ­­Is the staff member considered to be re-infected with SARS-CoV-2? □ Yes □ No If applicable, was the staff member symptomatic at the time of re-infection? □ Yes □ No
*VACCINATION STATUS: Indicate if the staff member received a COVID-19 vaccine 14 days or more before the specimen collection date: Not vaccinated: □ Not vaccinated with COVID-19 vaccine. □ First dose administered 13 days or less before the specimen collection date. Vaccinated: MM/YYYY Unknown MODERNA - Moderna COVID-19 vaccine PFIZBION - Pfizer-BioNTech COVID-19 vaccine JANSSEN – Janssen COVID-19 vaccine UNSPECIFIED – unspecified vaccine manufacturer *Dose 1 □ Yes □ No **Vaccination Date: <Drop down menu> ** Manufacturer: <Drop down menu> *Dose 2˅ □ Yes □ No **Vaccination Date: <Drop down menu> ** Manufacturer: <Drop down menu> *Additional Dose 3± □ Yes □ No **Vaccination Date: <Drop down menu> ** Manufacturer: <Drop down menu> * Additional Dose 4± □Yes □ No **Vaccination Date: <Drop down menu> ** Manufacturer: <Drop down menu> ˅second dose received 14 days or more before the specimen collection date; otherwise, count as only dose 1. ± Additional dose received 14 days or more before the specimen collection date.
*COVID-19 DEATH: Did the staff member die from COVID-19 related complications? □ Yes □ No **Date of death __/__/____
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 (0920-1306). CDC 57.160 (Front) September 2021 V9