Form 0920-1317 VA - Staff and Personnel COVID-19 Event Form

OMB Approved

OMB No. 0920-1317

Exp. Date 01/31/2024

www.cdc.gov/nhsn

*Facility ID:	Event #:
*Staff ID:
*Name: First: Middle: Last:
*Gender: F M Other	*Date of Birth: ___/___/____
*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
Event Details
*Event Type: COVID-19		*Date of Event: __/__/____

Staff COVID-19 Event Form

*VACCINATION STATUS

Indicate the vaccination status of the staff member on the event date or date of specimen collection.

Has the staff member received any COVID-19 vaccine? □ Yes □ No

Which vaccine was received (select all that apply)?

• Pfizer-BioNTech

• Moderna

• Johnson & Johnson’s Janssen

• Unspecified

**PRIMARY SERIES

Indicate the date(s) for each vaccine received.

**Dose 1 Date: ___________(MM/DD/YYYY)

**Dose 2 Date: _________ (MM/DD/YYYY) □ Not received

**ADDITIONAL OR BOOSTER DOSES

Indicate the date(s) for any additional or booster doses of vaccine received.

*Has the staff member received any additional or booster doses of vaccine? □ Yes □ No

Date: ___________ (MM/DD/YYYY) Date: ___________ (MM/DD/YYYY) Date: ___________ (MM/DD/YYYY)

*COVID-19 DEATH

Did the staff member die from COVID-19 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 30 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 57.160 July 2022 V13