Page
2
of
2 *Required
to
save;
**Conditional
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SARS-CoV-2
Resident Hospitalizations
|
*HOSPITALIZATIONS:
Number
of residents who were admitted to the hospital for COVID-19 or
related complications _____.
Include
only the number of new hospitalizations since the most recent date
data were reported to NHSN.
|
Re-Infections
with SARS-CoV-2
|
**RE-INFECTIONS:
Based
on
the
number
reported
for
Positive
Tests,
indicate
how
many
met
NHSN
definition for
re-infection:
SYMPTOMATIC:
Based
on
the
number
reported
for
Re-Infections,
indicate
how
many
of the residents had
signs and/or symptoms consistent with
COVID-19:
______.
ASYMPTOMATIC:
Based
on
the
number
reported
for Re-Infections,
indicate
how
many
of the residents 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:
____.
Include
only the number of new deaths since the most recent date data were
reported to NHSN..
**COVID-19
DEATHS:
Based
on
the
number
reported
for
Total
Deaths,
indicate
the
number
of
residents
who died from COVID-19 or related complications, either 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).
|
SARS-CoV-2
TESTING
|
Since
the last date of data entry in the Module, has your LTCF performed
SARS-CoV-2 (COVID-19) viral testing on residents and/or staff?
□
YES
□ NO
**
If, YES,
enter the number of SARS-CoV-2 (COVID-19) viral test(s) that were
performed using the following categories:
**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?
|
During
the past two weeks, on average, how long did it take your LTCF to
receive SARS-CoV-2 viral test results from NON- point-of-care
tests? (Select
ONE)
|
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? □
YES □ NO
|
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? □ 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 60 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 (0920-1317). CDC
57.144 (Front) v.10 (07-2021)
|
OMB
Approved