Form 0920-1317 Hospital Respiratory Data Weekly Reporting Form

Form Approved

O MB no. 0920-1317

Exp. Date: 03/31/2026

www.cdc.gov/nhsn

Page 3 of 3

Hospital Respiratory Data Weekly Reporting Form

*Required for submission

Facility Information
1	a.	NHSN Org ID*
	b.	Reporting Context*
	d.	Weekending Date*

Staffed Bed Capacity, Occupancy, and Prevalent Hospitalizations
Important: Please ensure that the values reported for the Staffed Bed Capacity and Prevalent Hospitalization fields are not aggregated to weekly totals. The data should provide a single day snapshot of the overall, adult, and pediatric inpatient and ICU bed capacity and occupancy and COVID, influenza, and RSV prevalent hospitalizations specifically for Wednesday of the reporting week.
Staffed Bed Capacity and Occupancy
Inpatient Beds				ICU Beds
2a. All hospital inpatient beds *		3a. All hospital inpatient occupancy*			4a. All ICU beds*		5a. All ICU bed occupancy*
2b. All adult inpatient beds*		3b. All adult inpatient occupancy*			4b. Adult ICU beds*		5b. Adult ICU bed occupancy*
2c. All pediatric inpatient beds *		3c. All pediatric inpatient occupancy *			4c. Pediatric ICU beds*		5c. Pediatric ICU bed occupancy*

Prevalent Hospitalizations – COVID-19
All hospitalizations		ICU hospitalizations
6a. All hospitalized adult patients with laboratory- confirmed COVID-19*			9a. Adult ICU patients with laboratory-confirmed COVID-19 *
6b. All hospitalized pediatric patients with laboratory-confirmed COVID-19*			9b. Pediatric ICU patients with laboratory-confirmed COVID-19*

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 202 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 H21-8, Atlanta, GA 30333, ATTN:  PRA (0920-1317). CDC Rev (R11.6 – 10/21/2023)               

Prevalent Hospitalizations – Influenza
All hospitalizations		ICU hospitalizations
7a. All hospitalized adult patients with laboratory-confirmed influenza*			10a. Adult ICU patients with laboratory-confirmed influenza*
7b. All hospitalized pediatric patients with laboratory-confirmed influenza*			10b. Pediatric ICU patients with laboratory-confirmed influenza*

Prevalent Hospitalizations – RSV
All hospitalizations		ICU hospitalizations
8a. All hospitalized adult patients with laboratory-confirmed RSV*			11a. Adult ICU patients with laboratory-confirmed RSV*
8b. All hospitalized pediatric patients with laboratory-confirmed RSV*			11b. Pediatric ICU patients with laboratory-confirmed RSV*

Weekly Total New Hospital Admissions (Sunday-Saturday)

Important: Data reported for the COVID-19, Influenza, and RSV new hospital admissions should reflect aggregate weekly totals for these fields. Please provide the weekly total new hospital admissions for the Sunday-Saturday reporting week.

Total New Hospital Admissions for Reporting Week – COVID-19
Pediatric patients			Adult patients
12a. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 0-4 years of age*			12c. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 18-49 years of age*
12b. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 5-17 years of age*			12d. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 50-64 years of age*
			12e. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 65-74 years of age*
			12f. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, 75+ years of age*
			12g. Weekly total number of new admissions of patients with laboratory-confirmed COVID-19, unknown age
Total New Hospital Admissions for Reporting Week – Influenza
Pediatric patients			Adult patients
13a. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 0-4 years of age*			13c. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 18-49 years of age*
13b. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 5-17 years of age*			13d. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 50-64 years of age*
			13e. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 65-74 years of age*
			13f. Weekly total number of new admissions of patients with laboratory-confirmed influenza, 75+ years of age*
			13g. Weekly total number of new admissions of patients with laboratory-confirmed influenza, unknown age

Total New Hospital Admissions for Reporting Week – RSV
Pediatric patients			Adult patients
14a. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 0-4 years of age*			14c. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 18-49 years of age*
14b. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 5-17 years of age*			14d. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 50-64 years of age*
			14e. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 65-74 years of age*
			14f. Weekly total number of new admissions of patients with laboratory-confirmed RSV, 75+ years of age*
			14g. Weekly total number of new admissions of patients with laboratory-confirmed RSV, unknown age

Optional

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

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

PPE
15a. On hand supply (DURATION in days) n95 respirators		16a. Are you able to MAINTAIN at least a 3-day supply of these items (y/n/N/A)? N95 respirators
15b. On hand supply (DURATION in days) surgical and procedure masks		16b. Are you able to MAINTAIN at least a 3-day supply of these items (y/n/N/A)? Surgical and procedure masks
15c. On hand supply (DURATION in days) eye protection including face shields and goggles		16c. Are you able to MAINTAIN at least a 3-day supply of these items (y/n/N/A)? Eye protection including face shields and goggles
15d. On hand supply (DURATION in days) single use gowns		16d. Are you able to MAINTAIN at least a 3-day supply of these items (y/n/N/A)? Single use gowns
15e. On hand supply (DURATION in days) exam gloves (sterile and non-sterile)		16e. Are you able to MAINTAIN at least a 3-day supply of these items (y/n/N/A)? Exam gloves