INSTRUCTIONS - Resident COVID-19 Event Form JUL2022

May 2021 (V.7) July 2022 (V.10)

Instructions for completion of the Resident COVID-19 Event Form

Description

As part of CDC’s ongoing COVID-19 response, the Resident COVID-19 Event Form is designed to help long-term care facilities (LTCFs) track and monitor residents who test-positive for COVID-19 (SARS-CoV-2). LTCFs eligible to report data include State Veterans Homes (SVH) providing nursing home (LTC-SVHSNF) and domiciliary care (LTC-SVHALF). LTCFs that are not currently enrolled in NHSN will need to complete enrollment before the COVID-19 Module resident event form is accessible.

Definitions

An event form must be entered each time a resident newly tests positive for COVID-19, including residents who test positive during re-admission.

• Resident COVID-19 Event: a resident who tests positive for COVID-19 based on a point-of-care (POC) antigen or a Nucleic Acid Amplification Test (NAAT)-polymerase chain reaction (PCR) viral test result. Antibody test results should not be reported. This does not include residents who have a positive SARS-CoV-2 antigen test that is followed by a negative SARS-CoV-2 NAAT (PCR).

  • The PCR will need to be performed within 2 calendar days (date of specimen collection is calendar day 1) of the initial antigen test for this rule to apply.

• Re-admission: a resident who was discharged from the LTCF for more than 3 days and has been readmitted for a subsequent stay.

Data Field	Instructions for Form Completion
Facility ID	The facility ID will be auto populated by the system.
Event ID	Event ID number will be auto populated by the system.
Resident ID	Required. This is the resident identifier assigned by the facility and may consist of any combination of numbers and/or letters. This should be an ID that remains the same for the resident across all admissions and stays reported to NHSN. Note: If the resident tested is a “Veteran Spouse,” “Gold Star Parent,” or “Other,” enter an alphanumeric ID number. This is a number assigned by the facility and may consist of any combination of numbers and/or letters.
Medicare number	Optional. Enter the resident Medicare number or comparable railroad insurance number.
Resident Name	Required. Enter the first and last name of the resident. Middle name is optional.
Gender	Required. Select Female, Male, or Other to indicate the gender of the resident tested.
Date of Birth	Required. Record the date of the resident’s birth using this format: MM/DD/YYYY.
Ethnicity (specify)	Collecting ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups. Required. Specify if the resident is either Hispanic or Latino or Not Hispanic or Not Latino. Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. * Note: The resident should always be asked to identify their ethnicity. If the resident is unable to provide this information, ask a family member. If all good faith attempts to identify the ethnicity of the resident have failed, one of the following options may be chosen, as appropriate:    Declined to respond  Unknown * https://www.census.gov/topics/population/hispanic-origin/about.html
Race (specify)	Collecting ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups. Required. Specify one, or more, if necessary (i.e., bi-racial), of the choices below to identify the resident’s race (select no more than 2 options): American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander White Note: Hispanic or Latino is not a race. A person may be of any race while being Hispanic or Latino. The resident should always be asked to identify their race. If all good faith attempts to identify the race of the resident have failed, one of the following options may be chosen, as appropriate:    Declined to respond  Unknown
Veteran Resident Type	Required. Does the resident live in a State Veterans Home? If “Yes” is selected, choose whether the resident is a Veteran, Veteran Spouse, Gold Star Parent, or Other from the drop-down menu. If “Other” is selected, please enter the resident type in the space provided.

Event Information: Answers to the questions below are based on the current COVID-19 event being reported.
Data Field	Instructions for Form Completion
Event Type	Required. Event type = COVID-19
Date of Current Admission to Facility	Required. The date of current admission is the most recent date the resident entered the facility. Select the date of current admission using the drop-down calendar. Notes: Date of current admission must occur ON or BEFORE the date of event. If the resident tests positive upon readmission to the facility, a new event form should be completed using the new admission date and the previously assigned resident ID.
Date of Event (Test Date)	Required: Enter the date the specimen was collected to perform SARS-CoV-2 (COVID-19) testing using the drop-down calendar or enter the date manually using format: MM/DD/YYYY. Note: DO NOT complete an event form for residents who have a positive SARS-CoV-2 antigen test followed by a negative SARS-CoV-2 NAAT (PCR). The PCR will need to be performed within 2 calendar days (date of specimen collection is calendar day 1) of the initial antigen test for this rule to apply. Note: Date of Event must occur ON or AFTER the current admission date.

Data Field	Instructions for Form Completion
* VACCINATION STATUS Indicate the vaccination status of the resident on the event date (date of specimen collection). Primary Series Additional or Booster Doses	Required. Indicate the resident’s COVID-19 vaccination status at the time of specimen collection for SARS-CoV-2 (COVID-19) testing. Has the resident received any COVID-19 vaccine? Select “Yes” if the resident had a history of prior COVID-19 vaccination on the event date (the date a specimen was collected for SARS-CoV-2 (COVID-19) testing); otherwise select “No.” If “Yes” is selected, indicate which vaccine (manufacturer) was received. Select all manufacturers that apply. If the manufacturer is not known, select “Unspecified.” Primary Series of COVID-19 vaccine: The dates for dose 1 and 2 must be entered if the resident received any combination of Pfizer-BioNTech, Moderna, Johnson & Johnson, and Unspecified for the primary COVID-19 vaccine series. If the resident only received Johnson & Johnson, the date of the single dose is required only. Dose 1: Enter the vaccination date in the space provided. If the vaccination date is not known, enter the most approximate date. Dose 2: Enter the vaccination date in the space provided. If the vaccination date is not known, enter the most approximate date. If the second dose has not been received at the time of specimen collection for SARS-CoV-2 (COVID-19) viral testing, select “Not Received.” Note: Individuals who received all recommended doses of a COVID-19 vaccine that is neither approved nor authorized by the FDA but listed for emergency use by the World Health Organization (WHO) should be documented as “Unspecified Manufacturer” if they provide documentation of vaccination. Please refer to Interim Clinical Considerations for Use of COVID-19 Vaccines for the complete list of COVID-19 vaccines that have received an emergency use listing from WHO. Has the resident received any Additional or Booster doses of COVID-19 vaccine? Select “YES” if the resident with a newly positive SARS-CoV-2 viral test result received an additional or booster dose of COVID-19 vaccine after the initial series of vaccination was completed; otherwise select “No.” Example: reply “YES” if the resident received 2 doses of the Pfizer mRNA vaccine and received an additional dose or booster dose before the event date. Additional or Booster Dose: Enter the vaccination date(s) in the space provided. If the resident has received one or more additional or booster doses of COVID-19 vaccine, list the dates in the spaces provided as applicable. If the vaccination date is not known, enter the most approximate date. Important: Vaccination status is to be reported for residents with a newly positive SARS-CoV-2 viral test result. Include residents who received the vaccine while in the LTCF or outside of the LTCF. A booster shot is administered when a person has completed their primary vaccine series and protection against the virus has decreased over time. Additional doses are administered to people with moderately to severely compromised immune systems. This additional dose of an mRNA-COVID-19 vaccine is intended to improve immunocompromised people’s response to their initial vaccine series. Please follow CDC recommendations regarding the administration of additional or booster doses of COVID-19 vaccines.
*COVID-19 Therapy Indicate if the resident received one of the therapeutic options for the current COVID-19 event.	A Therapeutic is defined as a treatment, therapy, or drug. Monoclonal antibodies are examples of anti-SARS-CoV-2 antibody-based therapeutics used to help the immune system recognize and respond more effectively to the COVID-19 virus. Required. Select “Did not receive,” if the resident has not received monoclonal antibody therapy. If the resident received a monoclonal antibody therapeutic, select the appropriate therapeutic that was administered to the resident. Select “YES,” if the resident was treated with in-house stock that was stored at your facility (specifically, either administered by your LTCF or by an outside entity using stock provided by your LTCF). If the resident was not treated with in-house stock, select “NO.”
*Hospitalization (Transferred to an acute care facility)	Required. Select “YES,” if the resident was transferred to an acute care facility (hospital, long-term acute care hospital, or acute inpatient rehabilitation facility only) for this COVID-19 event, otherwise select “NO.” Notes: It is possible that a resident will be admitted to a hospital after a COVID-19 event is reported to NHSN. If the resident is later transferred to an acute care facility to receive treatment related to this COVID-19 event, previously submitted NHSN data must be edited to include the hospitalization and hospitalization date. The hospitalization date must be the date of transfer to the hospital. This would include residents that are transferred to an acute care facility NOT for COVID-19 and then subsequently found by the acute care facility to be COVID-19 positive.
*COVID-19 Death Indicate if the resident died from COVID-19 related complications while in the facility or another location.	COVID-19 Deaths: Defined by NHSN as residents who died from SARS-CoV-2 (COVID-19) related complications and includes resident deaths in the facility AND in other locations, such as an acute care facility, in which the resident with COVID-19 was transferred to receive treatment. Required. Select “YES” if the resident identified with a newly positive COVID-19 viral test result, had signs and/or symptoms of COVID-19 as defined by the CDC, was on transmission-based precautions for COVID-19, or died from ongoing complications related to a previous COVID-19 infection. Select “NO,” if the resident did not die, or if the resident’s death was not related to COVID-19 or a COVID-19 related complication. Notes: If the resident dies after the COVID-19 event data are entered in NHSN, previously submitted NHSN data must be edited to include the date of death. If the facility receives an autopsy result indicating a positive SARS-CoV-2 viral test result for a resident who was not initially documented as COVID-19 positive, a new event form will need to be completed rather than editing/modifying previously entered NHSN data. Residents discharged (specifically, not expected to return to the facility) from the facility are excluded and the date of death is not required.

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