Form 57.102 Hospital Respiratory Data Daily Reporting Form 14AUG2024

Form Approved

O MB no. 0920-1317

Exp. Date: 03/31/2026

www.cdc.gov/nhsn

Page 6 of 6

Hospital Respiratory Data Daily Reporting Form

*Required for submission

Facility Information
1	a.	NHSN OrgID*
	b.	Reporting Context*
	c.	Reporting For Date*
Staffed Bed Capacity, Occupancy, and Prevalent Hospitalizations
Hospitals are required to report this section of the form (specifically, capacity and hospitalization data fields) for Wednesday of the reporting week; however, facilities may report the capacity and hospitalization data fields daily, if they choose. Note, this is NOT applicable to the new admission section of this daily reporting form; please see new admission section for reporting information for those fields. For further guidance, please refer to the Table of Instructions (TOI).
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*
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*

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 58 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 - 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*

New Hospital Admissions (Sunday-Saturday)

Hospitals are required to report this section of the daily reporting form (specifically, new hospital admission data fields) each day of the reporting week (Sunday-Saturday). Note, this is NOT applicable to the capacity and hospitalizations sections of this daily reporting form; please see capacity and hospitalizations sections for reporting information for those fields. For further guidance, please refer to the Table of Instructions (TOI).

New Hospital Admissions – COVID-19
Pediatric patients			Adult patients
12a. Number of new admissions of patients with laboratory-confirmed COVID-19, 0-4 years of age*			12c. Number of new admissions of patients with laboratory-confirmed COVID-19, 18-49 years of age*
12b. Number of new admissions of patients with laboratory-confirmed COVID-19, 5-17 years of age*			12d. Number of new admissions of patients with laboratory-confirmed COVID-19, 50-64 years of age*
			12e. Number of new admissions of patients with laboratory-confirmed COVID-19, 65-74 years of age*
			12f. Number of new admissions of patients with laboratory-confirmed COVID-19, 75+ years of age*
			12g. Number of new admissions of patients with laboratory-confirmed COVID-19, unknown age
New Hospital Admissions – Influenza
Pediatric patients			Adult patients
13a. Number of new admissions of patients with laboratory-confirmed influenza, 0-4 years of age*			13c. Number of new admissions of patients with laboratory-confirmed influenza, 18-49 years of age*
13b. Number of new admissions of patients with laboratory-confirmed influenza, 5-17 years of age*			13d. Number of new admissions of patients with laboratory-confirmed influenza, 50-64 years of age*
			13e. Number of new admissions of patients with laboratory-confirmed influenza, 65-74 years of age*
			13f. Number of new admissions of patients with laboratory-confirmed influenza, 75+ years of age*
			13g. Number of new admissions of patients with laboratory-confirmed influenza, unknown age
New Hospital Admissions – RSV
Pediatric patients			Adult patients
14a. Number of new admissions of patients with laboratory-confirmed RSV, 0-4 years of age*			14c. Number of new admissions of patients with laboratory-confirmed RSV, 18-49 years of age*
14b. Number of new admissions of patients with laboratory-confirmed RSV, 5-17 years of age*			14d. Number of new admissions of patients with laboratory-confirmed RSV, 50-64 years of age*
			14e. Number of new admissions of patients with laboratory-confirmed RSV, 65-74 years of age*
			14f. Number of new admissions of patients with laboratory-confirmed RSV, 75+ years of age*
			14g. Number of new admissions of patients with laboratory-confirmed RSV, unknown age

Optional

The below fields are optional, and hospitals are not required to report them to the federal government.

Facilities may choose to report these fields daily or they may report them for only one day of the reporting week (i.e., Wednesday). For further guidance, please refer to the Table of Instructions (TOI).

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