Instructions for Point of Care Testing Form (CDC 57.155)

May 2021

Instructions for Point of Care Testing Form (CDC 57.155)

Data Field	Instructions for Data Collection/Entry
Facility ID	The NHSN-assigned facility ID will be auto-entered by the computer.
Type of Individual Tested	Required. From the drop-down menu, choose whether the testee is a resident of the facility, a staff/volunteer/contractor at the facility, or a visitor to the facility.
Resident ID	Conditionally Required. If the testee is a facility resident, enter the alphanumeric resident ID. This is the resident identifier assigned by the facility and may consist of any combination of numbers and/or letters. This should be an ID that remains the same for the resident across all admissions and stays. The system will not allow two individuals to share the same ID. Birthdates are NOT recommended as ID numbers.
Staff ID	Conditionally Required. If the testee is a staff/volunteer/contractor at the facility, enter an alphanumeric staff ID number. This is a number assigned by the facility and may consist of any combination of numbers and/or letters. The system will not allow two individuals to share the same ID. Birthdates are NOT recommended as ID numbers. NOTE: The NHSN Facility Administrator (FacAd) will be the only registered NHSN user in the facility to whom access to Staff point of care (POC) test data is automatically granted by NHSN. If other NHSN Users in the facility need the ability to enter or access Staff POC test data, the NHSN FacAd will need to grant such rights through the “Users” option in the blue navigation bar on the left side of the screen while in the NHSN application. Without the granting of such rights, Staff data screens will not be visible to the NHSN User.
Visitor ID	Conditionally Required. If the testee is a visitor to the facility, enter an alphanumeric Visitor ID number. This is a number assigned by the facility and may consist of any combination of numbers and/or letters. The system will not allow two individuals to share the same ID. Birthdates are NOT recommended as ID numbers.
Name	Required. Enter the first and last name of the individual tested. Middle name is optional. Names cannot contain numerals.
Gender	Required. Check Female, Male, or Other to indicate the gender of the individual tested.
Date of birth	Required. Record the date of the individual’s birth using this format: MM/DD/YYYY.
Ethnicity	Required. Specify if the individual is either Hispanic or Latino, or Not Hispanic or Not Latino. Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.* The resident should always be asked to identify their race and ethnicity. If the resident is not a good historian, then check with a reliable family member. NOTE: Collecting race and ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the wellbeing of racial and ethnic minority groups. However, if after all attempts it is not possible to obtain ethnicity information, the appropriate response below, may be chosen: Declined to respond Unknown * https://www.census.gov/topics/population/hispanic-origin/about.html
Race	Required. Specify one or more of the choices below to identify the individual’s race. NOTE: Collecting race and ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the wellbeing of racial and ethnic minority groups. American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander White Declined to respond Unknown This data should be based upon the individual respondent’s self-identification with regards to race. If the resident is a poor historian, solicit information from a reliable family member. NOTE: Hispanic or Latino is not a race. A person may be of any race while being Hispanic or Latino.
Address, line 1	Required. Enter the street number and name or P.O. Box for the testee. If the testee is a resident, the address will auto-populate with the facility’s address.
Address, line2	Optional. Enter any secondary address information for the testee such as suite number. If the testee is a resident, the address will auto-populate with the facility’s address.
City	Required. Enter the city of residence for the testee. If the testee is a resident, the address will auto-populate with the facility’s address.
State	Required. Enter the state of residence for the testee. If the testee is a resident, the state will auto-populate with the facility’s state.
Zip Code	Required. Enter the zip code for the testee’s residence. If the testee is a resident, the zip code will auto-populate with the facility’s zip code.
County	Required. Enter the county of the testee’s residence. If the testee is a resident, the address will auto-populate with the facility’s county.
Contact Phone	Required. Enter the phone number for testee. If the testee is a resident, the field will auto-populate with the facility’s phone number.
Ext	Optional. Enter any extension for the phone number of the testee. If the testee is a resident, the extension will auto-populate with the facility’s extension if one is specified for the facility.
Test Date	Required. Use the calendar option presented to indicate the date on which the specimen was tested, or enter the date manually using format: MM/DD/YYYY.
Device Name	Required. Field will auto-populate with the testing device which has been identified as the default device. If a device different from the default device was used, then choose that device from the drop-down menu. To change the default device for future test results, choose “Choose Default” from the POC Test Result screen, choose the new POC default device from the drop-down menu and choose Save as Default.
Specimen Source	Required. Choose the most accurate source for the specimen from the available choices. Choices presented will include only those acceptable for the type of POC device used and may include one or more of the following: Nasal Swab, Nasopharyngeal Swab, Venous whole blood, or Fingerstick whole blood.
Test Result	Required. Choose from one of the test results provided by the device in use and listed in the drop-down menu. Choices for the devices are as follows: Accula SARS-CoV-2 Test_Mesa Biotech Inc._EUA Positive Test for SARS-CoV-2 Negative Test for SARS-CoV-2 ADVAITE RapCov Rapdi COVID-19 Test IgG Positive IgG Negative Assure SARS-CoV-2 IgG IgG Positive IgG Negative Assure SARS-CoV-2 IgM IgM Positive IgM Negative BD Veritor System for Rapid Detection of SARS-CoV-2, Beckton, Dickinson and Company (BD)_EUA CoV2: + CoV2: - BinaxNOW COVID-19 Ag Card_Abbott Diagnostics Scarborough Inc-EUA Positive Negative Biofire SARS-CoV-2 SARS CoV-2 Detected SARS CoV-2 Not Detected CareStart COVID-19 Antigen test_Access Bio, Inc._EUA COVID-19 Positive COVID-19 Negative Cepheid LDT: Xpert Xpress SARS-CoV-2 DoD SARS CoV-2 Positive SARS CoV-2 Negative SARS CoV-2 Presumptive Positive Cepheid Xpert Xpress SARS-CoV-2/Flu/RSV SARS CoV-2 Positive SARS CoV-2 Negative Cobas SARS-CoV-2 SARS CoV-2 Detected SARS CoV-2 Not Detected Cue COVID-19 Test_Cue Health Inc_ EUA SARS CoV-2 POSITIVE SARS CoV-2 NEGATIVE ID NOW COVID-19_Abbott Diagnostics Scarborough, Inc. EUA SARS CoV-2 Positive SARS CoV-2 Presumptive Positive SARS CoV-2 NEGATIVE Lucira COVID-19 All-In-One Test Kit COVID-19 Positive COVID-19 Negative Luminostics Clip COVID Rapid Antigen Test COVID-19 Positive COVID-19 Negative LumiraDX SARS-CoV-2 Ag Test_LumiraDX UK Ltd_EUA Positive SARS Co-V-2-Ag Negative SARS Co-V-2-Ag Nirmidas SARS CoV-2 IgG IgG Positive IgG Negative Nirmidas SARS CoV-2 IgM IgM Positive IgM Negative Sofia SARS Antigen FIA, Quidel Corporation_EUA SARS Positive SARS Negative Quidel QuickVue SARS Antigen Test Positive Negative
Specimen Number	Required. The NHSN application will auto-populate this field with an incrementally identified number. However, if desired, a facility may edit the data field to record a different number assigned to the specimen.
Ordering Physician	Required. From the drop-down menu, choose name of physician ordering the test. The drop-down menu will have been populated by data previously provided by the facility via the Setup Physicians option in POC Test Result section.
Was person symptomatic?	Required. Enter Yes if testee had symptoms of COVID-19 at the time of the test. Enter No if testee was without symptoms. Enter Unknown if it is not known whether the testee had symptoms at the time of test.
Was person pregnant?	Required. Field will auto-populate with No. Edit field to Yes if testee was pregnant at the time of symptoms. Edit field to Unknown if pregnancy status is not known.
Address, line 1	Optional. Enter the street number and name or P.O. Box for the ordering physician’s place of practice. This may be the same as the facility’s address.
Address, line2	Optional. Enter any secondary address information, such as suite number, for the ordering physician’s place of practice. This may be the same as the facility’s address.
City	Optional. Enter the city of the ordering physician’s place of practice. This may be the same as the facility’s address.
State	Optional. Enter the state of the ordering physician’s place of practice. This may be the same as the facility’s address.
Zip Code	Required. Enter the zip code of the ordering physician’s place of practice. This may be the same as the facility’s address.
County	Optional. Enter the county of the ordering physician’s place of practice. This may be the same as the facility’s address.
Work Phone	Optional. Enter the phone number for the ordering physician’s place of practice, including area code. This may be the same as the facility’s phone number.
Ext	Optional. Enter any extension for the phone number of the ordering physician’s place of practice.

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