0920-1317 / CDC 57 Resident Impact and Facility Capacity Form 23MAY2022

OMB Approved

OMB No. 0920-1317

Exp. Date 01/31/2024

www.cdc.gov/nhs

COVID-19 Module

Long Term Care Facility: Resident Impact and Facility Capacity Pathway

Page 1 of 2 *Required to save; **Conditional

NHSN Facility ID: CMS Certification Number (CCN):

Facility Name: Facility Type:

*Date for which counts/responses are reported: _____/__________/_____ *Date Created: ______/___________/_______

Counts should be reported at least once during the reporting week and include only new counts since the last date counts were collected for reporting to NHSN If the count is zero, a “0” must be entered as the response. A blank response is equivalent to missing data.

Facility Capacity
	ALL BEDS
	*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: Enter the number of residents with a newly positive SARS-CoV-2 viral test result (for example, a positive SARS-CoV-2 antigen test and/or SARS-CoV-2 NAAT (PCR). Note: Do not include residents who have a positive SARS-CoV-2 antigen test, but a negative SARS-CoV-2 NAAT (PCR). Only include residents newly positive since the most recent date data were collected for NHSN reporting.

Vaccination Status of Residents with a Newly Confirmed SARS-CoV-2 Viral Test Result: Based on the number of residents with a newly positive SARS-CoV-2 viral test result identified above.
	**Primary Series	Not Vaccinated: Include residents who have not been vaccinated with a COVID-19 vaccine OR residents whose first dose was administered 13 days or less before the specimen collection date
		Partial Vaccination: Include residents who have received Only 1-dose of a two-dose mRNA vaccine (for example, Moderna, Pfizer-BioNTech, or dose 1 of unspecified COVID-19 vaccine).
		Complete Primary Vaccination Series: Include residents who have received Dose 1 and ˅Dose 2 of a two-dose mRNA vaccine (for example, Moderna or Pfizer-BioNTech, or dose 1 and ˅2 of unspecified COVID-19 vaccine) OR 1 Dose of the Janssen COVID-19 Vaccine. ˅second dose received 14 days or more before the specimen collection date; otherwise, count as only dose 1.
	**Additional or Booster Doses	Additional or Booster Vaccination: Include newly positive residents who have received any additional dose(s) or booster dose(s) of COVID-19 vaccine (any manufacturer) AND 14 days or more have passed before the specimen collection date. Include additional or booster dose received 14 days or more before the specimen collection date; otherwise, count as only primary series.
	Residents who received at least one or more booster dose of COVID-19 vaccine: Based on the number of residents with a newly positive SARS-CoV-2 viral test result identified above.
	**Booster Doses	One Booster: Include residents who have received only one booster dose of COVID-19 vaccine (any manufacturer) AND 14 days or more have passed before the specimen collection date.
		Two or More Boosters: Include residents who have received two or more booster doses of COVID-19 vaccine since March 29, 2022 AND 14 days or more have passed before the specimen collection date.
	**Up to Date Vaccination Status
	Up to Date: Include residents who are up to date with COVID-19 vaccines 14 days or more before the specimen collection date. Note: Please review the current definition of up to date Stay Up to Date with Your COVID-19 Vaccines | CDC

*Required to save; **Conditional
*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).
SARS-CoV-2 TESTING
*TESTING AVAILABILITY: 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 residents, staff and facility personnel if needed? □ YES □ NO

Supplies and PPE Shortages
* Urgent Need: Indicate if facility will no longer have any PPE supply items in 7 days ⎕YES ⎕NO
Infection Control Supply Item	**Urgent Need: Indicate if facility will no longer have the PPE supply item in 7 days
N95 Respirator	⎕YES ⎕NO
Face mask	⎕YES ⎕NO
Eye Protection, including goggles or face shields	⎕YES ⎕NO
Gowns	⎕ YES ⎕NO
Gloves	⎕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 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 (0920-1317). CDC 57.146 (Front) v.11 May 2022