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
|