Form 57.218 Weekly Respiratory Pathogen and Vaccination Summary for

[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

57.218 Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities-Clean Version

Weekly Resident COVID-19 Vaccination Cumulative Summary for Long-Term Care Facilities (manual)

OMB: 0920-1317

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Form Approved

OMB No. 0920-1317

Exp. Date: 03/31/2026

www.cdc.gov/nhsn

Weekly Respiratory Pathogen and Vaccination Summary for Residents of Long-Term Care Facilities (CDC 57.218, Rev10)


1 page *required for saving

Facility ID#:

Week of data collection (Monday – Sunday): __/__/____ – __/__/____

Date Last Modified: __/__/____

Flu / Respiratory Virus Season: YYYY-YYYY

1. * Number of residents staying in this facility for at least 1 day during the week of data collection


Cumulative Vaccination Coverage

2. Resident Vaccination: Among residents in Question #1:


2a. *Number of residents who are up to date with COVID-19 vaccines


2b. Number of residents who have received this season’s annual influenza vaccine (YYYY-YYYY)


2c. Number of residents who have received RSV vaccine


New Resident Cases (Positive Tests) and Hospitalizations During the Week of Data Collection

3. Resident Cases (Positive Tests):

3a. *COVID-19: Residents with a Positive Test


3ai. **Number of residents in Question #3a who received the up to date COVID-19 vaccine 14 days or more before the positive test


3b. Influenza: Residents with a Positive Test


3bi. **Number of residents in Question #3b who received this season’s annual influenza vaccine (YYYY-YYYY) 14 days or more before the positive test


3c. RSV: Residents with a Positive Test


3ci. **Number of residents in Question #3c who received RSV vaccine 14 days or more before the positive test


4. Residents Hospitalized with a Positive Test

4a. *COVID-19: Residents hospitalized this week, and had a positive test in the last 10 days


4ai. **Number of residents in Question #4a who received the up to date COVID-19 vaccine 14 days or more before the positive test


4b. Influenza: Residents hospitalized this week, and had a positive test in the last 10 days


4bi. **Number of residents in Question #4b who received this season’s annual influenza vaccine (YYYY-YYYY) 14 days or more before the positive test


4c. RSV: Residents hospitalized this week, and had a positive test in the last 10 days


4ci. ** Number of residents in Question #4c who received RSV vaccine 14 days or more before the positive test


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 25 minutes per response, 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 57.128 v.10 September 2024


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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.218 Vax LTC Combined Resident Form March 2024
SubjectNHSN Weekly COVID-19 Module
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-10-31

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