Form 57.510 COVID–19 Module - Dialysis Outpatient Facility

COVID–19 Module

Dialysis Outpatient Facility

Revised: May 2022

*required to save as complete

Facility Operational Information For the following questions, please collect data for the current reporting week. The reporting week is defined as Wednesday through Tuesday with reporting to occur on Wednesday by 3 PM ET. You should report on the same day each week, either close of business on Tuesday or Wednesday by the deadline. We advise you not to alternate reporting days.
_________	*Facility ID (OrgID)
_________	*CMS Certification Number (CCN)
_________	*Facility Name
_________	*Week of Data Collection
_________	*In-center Patient Census
_________	*Date last modified
_________	*Home Patient Census
_________	*Total Certified Stations
_________	*Isolation Stations included in Total Certified Stations
 Yes  No	*Is your facility a designated COVID unit?
 Yes  No	*Does your facility have designated COVID shifts?
________	*Total number of staff (physician, nurses, techs, environmental services, biomed, etc.) who worked at least 1 day during the current reporting week:
_________	*How many patients on the current in-center census reside in nursing homes?
_________	*How many patients on the current home census reside in nursing homes?

For the following questions, report data during the current reporting week which is Wednesday through Tuesday each week. For questions requiring counts, include only new data which has occurred during the current reporting week. Data should not be cumulative.

SARS-CoV-2 Positive (+) Patients and Staff
Patients
_________	*Number of patients who were tested for SARS-CoV-2 and had a positive SARS-CoV-2 test result during the current reporting week:
_________	*Number of newly confirmed in-center patients during the current reporting week:
_________	*Number of newly confirmed in-center patients that reside in nursing homes during the current reporting week:
_________	*Number of newly confirmed patients during the current reporting week that are home patients:
_________	*Number of SARS-CoV-2 positive patients who are currently admitted to the hospital during the current reporting week:
Staff
_________	*Number of newly confirmed staff during the current reporting week:

COVID-19 Vaccination Status – Primary Series: For the patients who tested positive during the current reporting week, provide counts for the following categories.
Not Vaccinated
_________	*Number of patients who have not been vaccinated with a COVID-19 vaccine OR patients whose first dose was administered 13 days or less before the test date:
Partial Vaccination
__________	*Number of patients who have received only 1-dose of a two-dose mRNA vaccine (e.g., Moderna, Pfizer-BioNTech, or dose 1 of unspecified COVID-19 vaccine) AND have tested positive 14 days or more after receiving the COVID-19 vaccine:
Complete Primary Vaccination Series
_________	*Number of patients who have received Dose 1 and Dose 2 of a two-dose mRNA vaccine (e.g., Moderna, Pfizer-BioNTech, or dose 1 and dose 2 of unspecified COVID-19 vaccine) OR 1 Dose of the Janssen COVID-19 Vaccine AND have tested positive 14 days or more after receiving the COVID-19 vaccine:

COVID-19 Vaccination Status – Additional and Booster Doses: For the patients who tested positive during the current reporting week, provide counts for the following. CDC Up-To-Date Vaccination Guidelines: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html
Additional or Booster Vaccination
__________	*Number of patients who have received any additional dose(s) or booster dose(s) of COVID-19 vaccine (any manufacturer) AND have tested positive 14 days or more after receiving the additional dose or booster dose:
Booster Doses
_________	*Number of patients who have received only one booster dose of COVID-19 vaccine (any manufacturer) AND have tested positive 14 days or more after receiving the booster dose:
_________	*Number of patients who have received two or more booster doses of COVID-19 vaccine (any manufacturer) AND have tested positive 14 days or more after receiving the most recent booster dose:

COVID-19 Deaths – Patients and Staff
_________	*Number of patients with deaths due to COVID-19 or related complications during the current reporting week:
_________	*Number of staff with deaths due to COVID-19 or related complications during the current reporting week:

For the following questions, please collect data and report findings during the current reporting week:

Shortages: Staff/Personnel & Personal Protective Equipment (PPE)
*Will your facility have a shortage of staff and/or personnel within the next week?	 Yes  No
*Will your facility have a shortage of PPE within the next week?	 Yes  No