0920-1317 COVID-19 Hospital Data Form

Form Approved

O MB no. 0920-1317

Exp. Date: 03/31/2026

www.cdc.gov/nhsn

Page 19 of 19

COVID-19 Hospital Data Form

*Required for submission

Entering Data For
Facility Information
1	a.	Facility Name*
	h.	HHS ID*
	b.	CCN*
		AHA ID
	c.	NHSN Org ID*
		Facility Type*
	d.	State*
	e.	County*
	f.	ZIP*
	g.	TeleTracking ID*
Hospitals, with the exception of psychiatric and rehabilitation hospitals, are required to report seven days a week but, where possible and pending further direction from their state or jurisdiction, are encouraged to report weekend data on the following Monday with the data backdated to the appropriate date. See HHS Guidance & FAQ.
It is critical to the COVID-19 response that all of the information listed below is provided to the Federal Government on the requested reporting schedule to facilitate planning, monitoring, and resource allocation during the COVID-19 Public Health Emergency (PHE). All fields are mandatory unless otherwise noted in the HHS Guidance & FAQ. Note: Provide data entries for all requested fields. Enter 0 or select N/A (if available) if the item is not applicable at your facility.

Staffed Bed Capacity
3a. All hospital inpatient beds*		4a. All hospital inpatient bed occupancy*		5a. ICU beds*		6a. ICU bed occupancy*
3b. Adult hospital inpatient beds*		4b. Adult hospital inpatient bed occupancy*		5b. Adult ICU beds*		6b. Adult ICU bed occupancy*
3c. All inpatient pediatric beds *		4c. Pediatric inpatient bed occupancy*		5c. Pediatric ICU beds*		6c. Pediatric ICU bed occupancy*

Hospitalizations
9b. Hospitalized adult laboratory confirmed COVID-19 patients*		10b. Hospitalized pediatric laboratory-confirmed COVID-19 patients*		12b. Hospitalized ICU adult laboratory-confirmed COVID-19 patients*
				12c. Hospitalized ICU pediatric laboratory-confirmed COVID-19 patients*

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 90 minutes, 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 D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666). CDC  Rev (R11.6 – 10/21/2023)               

Previous Day’s Admissions Note: The age brackets under fields 17a are required to be considered compliant.
Previous Day’s adult admissions with laboratory-confirmed COVID-19 and breakdown by age bracket:			Previous Day’s pediatric admissions with laboratory confirmed COVID-19 breakdown by age bracket:
17a. Total adult*			18a. Total pediatric*
18-19			0-4
20-29			5-11
30-39			12-17
40-49			Unknown
50-59
60-69
70-79
80+
Unknown

PPE
27b. N95 respirators*		30c. N95 respirators*
27c. Surgical and procedure masks*		30e. Surgical and procedure masks*
27d. Eye protection including face shields and goggles*		30f. Eye protection including face shields and goggles*
27e. Single-use gowns*		30g. Single-use gowns*
27f. Exam gloves (sterile and non-sterile)*		30h. Exam gloves*

Influenza
33. Total hospitalized patients with laboratory-confirmed influenza virus infection*		34. Previous day's influenza admissions (laboratory-confirmed influenza virus infection) *		35. Total hospitalized ICU patients with laboratory-confirmed influenza virus infection*

Optional – Respiratory Pathogens

The below fields are optional for the federal data collection. Hospitals are not required to report these data elements to the federal government.

Note: State, local, tribal, and territorial (SLTT) partners may have reporting requirements related to or independent of the federal reporting requirements. Facilities are encouraged to work with relevant (SLTT) partners to ensure complete reporting for all partners.

Influenza
33a. Hospitalized adult patients with laboratory-confirmed influenza virus infection		34a. Previous day’s adult admissions with laboratory-confirmed influenza virus infection		35a. Hospitalized ICU adult laboratory-confirmed influenza patients
33b. Hospitalized pediatric patients with laboratory-confirmed influenza virus infection		34b. Previous day’s pediatric admissions with laboratory-confirmed influenza virus infection		35b. Hospitalized ICU pediatric laboratory-confirmed influenza patients

RSV
48a. Previous day’s adult admissions with laboratory-confirmed RSV		49a. Hospitalized adult laboratory-confirmed RSV patients		50a. Hospitalized ICU adult laboratory-confirmed RSV patients
48b. Previous day’s pediatric admissions with laboratory-confirmed RSV		49b. Hospitalized pediatric laboratory-confirmed RSV patients		50b. Hospitalized ICU pediatric laboratory-confirmed RSV patients

Optional

The below fields have been made optional for the federal data collection. Hospitals no longer need to report these data elements to the federal government.

Note: State, local, tribal, and territorial (SLTT) partners may have reporting requirements related to or independent of the federal reporting requirements. Facilities are encouraged to work with relevant (SLTT) partners to ensure complete reporting for all partners.

Hospitalizations
9a. Total hospitalized adult suspected or laboratory-confirmed COVID-19 patients		10a. Total hospitalized pediatric suspected or laboratory confirmed COVID-19 patients		11. Hospitalized and ventilated COVID-19 patients		12a Total ICU adult suspected or laboratory-confirmed COVID-19 patients

Previous Day’s Admissions
	Previous Day’s adult admissions with suspected COVID-19 and breakdown by age bracket:			Previous Day’s pediatric admissions with suspected COVID-19:
	17b. Total adult			18b. Total pediatric
	18-19
	20-29
	30-39
	40-49
	50-59
	60-69
	70-79
	80+
	Unknown

Emergency Department
19. Previous day’s ED Visits		20. Previous day’s total COVID-19- related ED visits

Staff Note: Field 24 will always default to “No” for a new submission.
24. Critical staffing shortage anticipated within a week (Y/N)

Inactive Federal Data Collection
The below fields have been made inactive for the federal data collection. Hospitals no longer need to report these data elements to the federal government. Note: State, local, tribal, and territorial (SLTT) partners may have reporting requirements related to or independent of the federal reporting requirements. Facilities are encouraged to work with relevant (SLTT) partners to ensure complete reporting for all partners.
Staffed Bed Capacity
2a. All hospital beds
2b. All adult hospital beds

Ventilators
7. Total mechanical ventilators		8. Mechanical ventilators in use

Hospitalizations
13. Hospital onset

ED/Overflow
14. ED/overflow		15. ED/overflow and ventilated

Previous Day's COVID-19 Deaths
16. Previous Day's COVID-19 Deaths

Therapeutics Note: For fields 39a - 40d below, report one time a week on Wednesday.
Remdesivir		Bamlanivimab (Therapeutic B)
21. Previous day's Remdesivir used (Optional)		39c. Current inventory on hand (in courses) (Optional)
22. Current inventory (Optional)		39d. Courses used in the last week (Optional)

Casirivimab (REGN10933) / Imdevimab (REGN10987) (Therapeutic A)		Bamlanivimab and Etesevimab (Therapeutic C)				Sotrovimab (Therapeutic D)
39a. Current inventory on hand (in course)*			40a. Current inventory on hand (in course)*				40c. Current inventory on hand (in course)*
39b. Courses used in the last week*			40b. Courses used in the last week*				40d. Courses used in the last week*

⚠ Please note: Bamlanivimab is no longer authorized for use without accompanying Etesevimab. The value in the field 39d should be 0. Any doses of Bamlanivimab used with accompanying Etesevimab should be reported in field 40b.

Staff
23. Critical staffing shortage today (Y/N) (Optional)		25. Staffing shortage details (Optional)

PPE
26. PPE Supplies		27. On hand supply (DURATION IN DAYS):		28. On hand supply (INDIVIDUAL UNITS/”EACHES”) (Optional):		29. Are you able to obtain these items?
Are your PPE supply items managed (purchased, allocated, and/or stored) at the facility level or, if you are part of a health system, at the health system level (or other multiple facility group)?
		27a. Ventilator supplies		28a. N95 respirators (Optional)		29a. Ventilator supplies (any supplies excluding medications)
				28b. Other respirators such as PAPRs or elastomerics (Optional)		29b. Ventilator medications
				28c. Surgical and procedure masks (Optional)		29c. N95 Respirators
				28d. Eye protection including face shields and goggles (Optional)		29d. Other respirators such as PAPRs or elastomerics
				28e. Single-use gowns (Optional)		29e. Surgical and procedure masks
				28f. Launderable gowns (Optional)		29f. Eye protection including face shields and goggles
				28g. Exam gloves (single) (Optional)		29g. Single-use gowns
						29h. Exam gloves
						29i. Are you able to maintain a supply of launderable gowns?

30. Are you able maintain at least a three-day supply of these items?		31. Does your facility re-use or extend the use of PPE? (Optional)
				32. If there are any critical issues, such as supply, staffing, capacity, or other issues about which you would like to receive direct contact, please explain here. (Optional)
30a. Ventilator supplies (any supplies excluding medications)		31a. Reusable/launderable isolation gowns
30b Ventilator medications		31b. PAPRs or elastomerics
30d. Other respirators such as PAPRS or elastomerics		31c. N95 respirators
30i. Laboratory - nasal pharyngeal swabs
30j. Laboratory - nasal swabs
30k. Laboratory - viral transport media

Influenza
36. Total hospitalized patients co-infected with BOTH laboratory-confirmed COVID-19 AND laboratory-confirmed influenza virus infection (Optional)		37. Previous day's influenza deaths (laboratory-confirmed influenza virus infection) (Optional)		38. Previous day's deaths for patients co-infected with both COVID-19 AND laboratory-confirmed influenza virus (Optional)

Vaccinations

Vaccinations for Personnel

41. Previous week’s COVID-19 vaccination doses administered to healthcare personnel by your facility (Regardless of series or single-dose vaccine) (Optional)

42. Current healthcare personnel who have not yet received any COVID-19 vaccination doses (Optional)

43. Current healthcare personnel who have received the first dose of COVID-19 vaccination doses (Optional)

44. Current healthcare personnel who have received a completed series of a COVID-19 vaccination or a single-dose vaccination

45. Total number of current healthcare personnel (Optional)

Vaccinations for Patients

46. Previous week's number of patients and other nonhealthcare personnel who received the first dose in a multi-series of COVID-19 vaccination doses (Optional)

47. Previous week's number of patients who received the final dose in a series of COVID-19 vaccination doses or the single-dose vaccine by your facility (Optional)