Crosswalk 57.218_07SEP2023

Each form change and associated burden are described below.

Long-Term Care Component: Person-Level Vaccination Form – Resident & Weekly COVID-19 Vaccination Summary Form for Residents 57.218

The optional Person-Level Vaccination Form for Residents was developed to assist facilities with managing and tracking person-level vaccination data directly in NHSN and having the weekly summary totals automatically calculated and entered to the main Weekly Resident COVID-19 Vaccination Module by the

Application. This form is being modified based on our analysis of expanded vaccination data collection efforts. The modification to the Person-Level Forms will include adding RSV, Pneumococcal, and Influenza vaccination.

• Weekly COVID-19 Vaccination Summary Form for Residents at LTCFs Form 57.218

Time Burden: estimate 35 minutes to complete the form

Change in Time Burden: increase by 5 minutes

Justification for changes:

All CMS-certified Long Term Care facilities are required to enter COVID-19 vaccination data into the NHSN user application. These are suggested changes to add RSV, PNUEMO, and FLU Vaccination questions on the Person-Level Vaccination Form and Summary Form 51.218 for Residents (only). These suggested changes we are proposing are based on our analysis of compiling vaccine information on one form to simplify vaccine reporting.

Current	Proposed	Type of Change	Reason for Change	Impact to Burden
Person-Level Resident Form - New Question: RSV Vaccination	Include an additional column for RSV Vaccination should be added to the Person-Level Form - Residents Drop down box (either 'Yes', 'No', or Unknown)	Addition	Expand Person-Level Resident to include RSV, Pneumococcal, and influenza vaccination.	Increase
Person-Level Resident Form – New Question: Pneumococcal Vaccination	Include an additional column for Pneumococcal Vaccination should be added to the Person-Level Form - Residents Drop down box (either 'Yes', 'No', or Unknown)	Addition	Expand Person-Level Resident to include RSV, Pneumococcal, and influenza vaccination.	Increase
Person-Level Resident Form – New Question: Influenza Vaccination	Include an additional column for Influenza Vaccination should be added to the Person-Level Form - Residents Drop down box (either 'Yes', 'No', or Unknown)	Addition	Expand Person-Level Resident to include RSV, Pneumococcal, and influenza vaccination.	Increase
Resident Summary Form 57.218 - New Question: RSV Vaccination	Add Question 5: *Number of residents in question #1 who are up to date with RSV vaccination Add Question 5a: *Medical contraindication to RSV vaccine	Added question to form	Expand resident forms to include RSV, Pneumococcal, and influenza vaccination.	Increase
Resident Summary Form 57.218 - New Question: Pneumococcal Vaccination	Add Question 6: *Number of residents in question #1 who are up to date with Pneumococcal vaccination Add Question 6a: *Medical contraindication to Pneumococcal vaccine	Added question to form	Expand resident forms to include RSV, Pneumococcal, and influenza vaccination.	Increase
Resident Summary Form 57.218 - New Question: Influenza Vaccination	Add Question 7: *Number of residents in question #1 who are up to date with Influenza vaccination Add Question 7a: *Medical contraindication to Influenza vaccine	Added question to form	Expand resident forms to include RSV, Pneumococcal, and influenza vaccination.	Increase

Note:

Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation.

Impact to Burden: Yes = reduction or increase (if increase, please summarize impact), None.

		Number of Facilities completing the form  (Annual)	Number of times the form is completed at each facility  (Annual)	Time it takes to complete all data collection requirements (Hours)
Form Number	Form Name	08/2023	08/2023	08/2023
57.218	Weekly Vaccination Cumulative Summary for Residents of Long-Term Care Facilities (57.218)	15,925	52 times (LTCFs report this data each week of the year)	For this form, CDC estimates that it may take about 30 minutes to complete reporting for each week the form is being used. The total burden time will depend upon how long data reporting is required.