Form CDC 57.145 CDC 57.145 Staff and Personnel Impact

O MB Approved

OMB No. 0920-1209

Exp. Date 01/31/2024

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Staff and Personnel Impact

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: _____/________/_____

Counts should be reported at least once during the reporting week and 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.

Staff and Personnel Impact

*POSITIVE TESTS: Enter the number of staff and facility personnel 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: Exclude staff and facility personnel who have a positive SARS-CoV-2 antigen test, but a negative SARS-CoV-2 NAAT (PCR). Include only staff and facility personnel newly positive since the most recent date data were collected for NHSN reporting

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 5 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 (0920-1306). CDC 57.145 (Front) v.5 June 2023