Form CDC 57.144 CDC 57.144 Resident Impact and Facility Capacity

OMB Approved

OMB No. 0920-1317

Exp. Date 01/31/2024

www.cdc.gov/nhs

COVID-19 Module Long Term Care Facility: Resident Impact and Facility Capacity Pathway

Page 1 of 2 *Required to save; **Conditional

NHSN Facility ID: CMS Certification Number (CCN):

Facility Name: Facility Type:

*Date for which counts/responses are reported: _____/__________/_____ *Date Created: ______/___________/_______

Include only new counts since the last date counts were collected for reporting to NHSN If the count is zero, a “0” must be entered as the response. A blank response is equivalent to missing data.

Facility Capacity
	ALL BEDS
	*CURRENT CENSUS: Total number of beds that are occupied on the reporting calendar day

Positive Tests and Vaccination Status of Newly Positive Residents

______ * POSITIVE TESTS: Enter the number of residents with a newly positive SARS-CoV-2 viral test result (for example, a positive SARS-CoV-2 antigen test and/or SARS-CoV-2 NAAT (PCR).

Note: Do not include residents who have a positive SARS-CoV-2 antigen test, but a negative SARS-CoV-2 NAAT (PCR).

Only include residents newly positive since the most recent date data were collected for NHSN reporting.

_____ **UP TO DATE: Include residents with a newly positive SARS-CoV-2 viral test result who are up to date with COVID-19 vaccines 14 days or more before the specimen collection date.

Note: Please review the current NHSN surveillance definition of up to date

NOT UP TO DATE: ____

Based on the counts entered for POSITIVE TESTS and UP TO DATE, the count for residents who are NOT considered up to date based on the NHSN Surveillance definition has been calculated above.

This count is not editable, to edit please update the count entered for UP TO DATE.

Hospitalizations

This is not a subset of the “Positive Tests” count reported above. Include only the number of new hospitalizations with a positive COVID-19 test since the most recent date data were reported to NHSN.

_____ *Hospitalizations with a positive COVID-19 Test: Number of residents who have been hospitalized with a positive COVID-19 test.

Note: Only include residents who have been hospitalized during this reporting period and had a positive COVID-19 test in the 10 days prior to the hospitalization, date of specimen collection is calendar day 1.

____ ** Hospitalizations with a positive COVID-19 Test and Up to Date: Based on the number reported above for “Hospitalizations with a positive COVID-19 Test”, indicate the number of residents who were hospitalized with a positive COVID-19 test and also up to date with COVID-19 vaccinations at the time of the positive COVID-19 test.

Deaths

_____ *TOTAL DEATHS: Number of residents who have died for any reason in the facility or another location

Include only the number of new deaths since the most recent date data were reported to NHSN.

______ **COVID-19 DEATHS: Based on the number reported for Total Deaths, indicate the number of residents who died from COVID-19 or related complications, either in the facility or another location.

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)).

CDC estimates the average public reporting burden for this collection of information as 15 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-1317). CDC 57.144 (Front) v.14 June 2023