OMB
Approved
OMB No. 0920-1317
Exp. Date 01/31/2024
www.cdc.gov/nhsn
*Facility ID: |
Event #: |
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*Resident ID: |
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Medicare number (or comparable railroad insurance number): |
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*Resident Name: First: Middle: Last: |
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*Gender: F M Other |
*Date of Birth: ___/___/____ |
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*Ethnicity (specify): □ Hispanic or Latino □ Not Hispanic or Latino □ Declined to respond □ Unknown |
*Race (specify): □ American Indian/Alaska Native □ Asian □ Black or African American □ Native Hawaiian/Other Pacific Islander □ White □ Declined to respond □ Unknown |
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*Is the resident in a State Veterans Home? □ Yes □ No
**Veteran Resident Type: □Veteran □Veteran Spouse □Gold Star Parent □Other (Specify) |
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Event Details |
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*Event Type: COVID-19 |
*Date of Current Admission to Facility: __/__/____ |
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*Date of Event: __/__/____ |
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Resident COVID-19 Event Form
*VACCINATION STATUS Indicate the vaccination status of the resident on the event date or date of specimen collection. |
Has the resident received any COVID-19 vaccine? □ Yes □ No Which vaccine was received (select all that apply)?
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**PRIMARY SERIES Indicate the date(s) for each vaccine received. |
**Dose 2 Date: ___________ (MM/DD/YYYY) □ Not received |
**ADDITIONAL OR BOOSTER DOSES Indicate the date(s) for any additional or booster doses of vaccine. |
*Has the resident received any additional or booster doses of vaccine? □ Yes □ No
Date: __________ (MM/DD/YYYY) Date: __________ (MM/DD/YYYY) Date: __________ (MM/DD/YYYY)
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*COVID-19 THERAPY Indicate if the resident received one of the following therapeutic options for the current COVID-19 event (positive SARS CoV-2 viral test result): |
□ Did not receive
□ Casirivimab/Imdevimab (Regeneron) Received therapy from stock stored at this facility? □ Yes □ No
□ Bamlanivimab/etesevimab (Lilly) Received therapy from stock stored at this facility? □ Yes □ No
□ Sotrovimab (GlaxoSmithKline) Received therapy from stock stored at this facility? □ Yes □ No
□ Evusheld (AstraZeneca) Received therapy from stock stored at this facility? □ Yes □ No
□ Paxlovid (Pfizer) Received therapy from stock stored at this facility? □ Yes □ No
□ Molnupiravir (Merck) Received therapy from stock stored at this facility? □ Yes □ No
□ Bebtelovimab (Lilly) Received therapy from stock stored at this facility? □ Yes □ No |
*HOSPITALIZATION |
Has the resident been admitted to a hospital or transferred to an acute care facility for this COVID-19 event? □ Yes □ No **Date of hospitalization __/__/____ |
*COVID-19 DEATH |
Did the resident die from COVID-19 or 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 35 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 57.159 July 2022 V15 |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | COVID-19 Form Resident Impact and Facility Capacity |
Subject | NHSN LTCF COVID-19 |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2023-09-08 |