0920-1317 Weekly Respiratory Pathogen and Vaccination Summary for

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (CDC 57.218, Rev10)

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Facility ID#:
Week of data collection (Monday – Sunday): __/__/____ – __/__/____		Date Last Modified: __/__/____
1. * Number of residents staying in this facility for at least 1 day during the week of data collection
Cumulative Vaccination Coverage
2. Resident Vaccination: Among residents in Question #1:
2a. *Number of residents who are up to date with COVID-19 vaccines
2b. *Number of residents who have received this season’s annual influenza vaccine
2c. *Number of residents who have received RSV vaccine
New Resident Cases (Positive Tests) and Hospitalizations During the Week of Data Collection
3. Resident Cases (Positive Tests):
3a. *COVID-19: Residents with a Positive Test
**Number of residents in Question #3a who are up to date with COVID-19 vaccines
3b. *Influenza: Residents with a Positive Test
**Number of residents in Question #3b who have received this season’s annual influenza vaccine
3c. *RSV: Residents with Positive Tests
**Number of residents in Question #3c who have received RSV vaccine
4. Residents Hospitalized with a Positive Test
4a. *COVID-19: Residents hospitalized within 10 days after a positive test
**Number of residents in Question #4a who are up to date with COVID-19 vaccines
4b. *Influenza: Residents hospitalized within 10 days after a positive test
**Number of residents in Question #4b who have received this season’s annual influenza vaccine
4c. *RSV: Residents hospitalized within 10 days after a positive test
** Number of residents in Question #4c who have received RSV vaccine
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)). Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data 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, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-0666). CDC 57.128 v.10 September 2024

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