May 2021 (V.7) July 2022 (V.10)
Instructions for completion of the Resident COVID-19 Event Form
As part of CDC’s ongoing COVID-19 response, the Resident COVID-19 Event Form is designed to help long-term care facilities (LTCFs) track and monitor residents who test-positive for COVID-19 (SARS-CoV-2). LTCFs eligible to report data include State Veterans Homes (SVH) providing nursing home (LTC-SVHSNF) and domiciliary care (LTC-SVHALF). LTCFs that are not currently enrolled in NHSN will need to complete enrollment before the COVID-19 Module resident event form is accessible.
Definitions
An event form must be entered each time a resident newly tests positive for COVID-19, including residents who test positive during re-admission.
Resident COVID-19 Event: a resident who tests positive for COVID-19 based on a point-of-care (POC) antigen or a Nucleic Acid Amplification Test (NAAT)-polymerase chain reaction (PCR) viral test result. Antibody test results should not be reported. This does not include residents who have a positive SARS-CoV-2 antigen test that is followed by a negative SARS-CoV-2 NAAT (PCR).
The PCR will need to be performed within 2 calendar days (date of specimen collection is calendar day 1) of the initial antigen test for this rule to apply.
Re-admission: a resident who was discharged from the LTCF for more than 3 days and has been readmitted for a subsequent stay.
Data Field |
Instructions for Form Completion |
Facility ID |
The facility ID will be auto populated by the system. |
Event ID |
Event ID number will be auto populated by the system. |
Resident ID |
Required. This is the resident identifier assigned by the facility and may consist of any combination of numbers and/or letters. This should be an ID that remains the same for the resident across all admissions and stays reported to NHSN.
Note: If the resident tested is a “Veteran Spouse,” “Gold Star Parent,” or “Other,” enter an alphanumeric ID number. This is a number assigned by the facility and may consist of any combination of numbers and/or letters.
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Medicare number |
Optional. Enter the resident Medicare number or comparable railroad insurance number. |
Resident Name |
Required. Enter the first and last name of the resident. Middle name is optional. |
Gender
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Required. Select Female, Male, or Other to indicate the gender of the resident tested. |
Date of Birth |
Required. Record the date of the resident’s birth using this format: MM/DD/YYYY.
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Ethnicity (specify)
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Collecting ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups.
Required. Specify if the resident is either Hispanic or Latino or Not Hispanic or Not Latino.
Hispanic or Latino is defined as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. *
Note: The resident should always be asked to identify their ethnicity. If the resident is unable to provide this information, ask a family member. If all good faith attempts to identify the ethnicity of the resident have failed, one of the following options may be chosen, as appropriate:
* https://www.census.gov/topics/population/hispanic-origin/about.html
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Race (specify) |
Collecting ethnicity is important for understanding trends in the COVID-19 pandemic and ensuring the well-being of racial and ethnic minority groups.
Required. Specify one, or more, if necessary (i.e., bi-racial), of the choices below to identify the resident’s race (select no more than 2 options):
Note: Hispanic or Latino is not a race. A person may be of any race while being Hispanic or Latino. The resident should always be asked to identify their race. If all good faith attempts to identify the race of the resident have failed, one of the following options may be chosen, as appropriate:
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Veteran Resident Type |
Required. Does the resident live in a State Veterans Home? If “Yes” is selected, choose whether the resident is a Veteran, Veteran Spouse, Gold Star Parent, or Other from the drop-down menu.
If “Other” is selected, please enter the resident type in the space provided.
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Event Information: Answers to the questions below are based on the current COVID-19 event being reported. |
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Data Field |
Instructions for Form Completion |
Event Type |
Required. Event type = COVID-19 |
Date of Current Admission to Facility |
Required. The date of current admission is the most recent date the resident entered the facility. Select the date of current admission using the drop-down calendar.
Notes:
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Date of Event (Test Date) |
Required: Enter the date the specimen was collected to perform SARS-CoV-2 (COVID-19) testing using the drop-down calendar or enter the date manually using format: MM/DD/YYYY.
Note: DO NOT complete an event form for residents who have a positive SARS-CoV-2 antigen test followed by a negative SARS-CoV-2 NAAT (PCR).
Note: Date of Event must occur ON or AFTER the current admission date. |
Data Field |
Instructions for Form Completion |
* VACCINATION STATUS Indicate the vaccination status of the resident on the event date (date of specimen collection).
Primary Series
Additional or Booster Doses
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Required. Indicate the resident’s COVID-19 vaccination status at the time of specimen collection for SARS-CoV-2 (COVID-19) testing. Has the resident received any COVID-19 vaccine?
Primary Series of COVID-19 vaccine: The dates for dose 1 and 2 must be entered if the resident received any combination of Pfizer-BioNTech, Moderna, Johnson & Johnson, and Unspecified for the primary COVID-19 vaccine series. If the resident only received Johnson & Johnson, the date of the single dose is required only.
Note:
Has the resident received any Additional or Booster doses of COVID-19 vaccine?
Example: reply “YES” if the resident received 2 doses of the Pfizer mRNA vaccine and received an additional dose or booster dose before the event date.
Additional or Booster Dose: Enter the vaccination date(s) in the space provided. If the resident has received one or more additional or booster doses of COVID-19 vaccine, list the dates in the spaces provided as applicable. If the vaccination date is not known, enter the most approximate date. Important:
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*COVID-19 Therapy
Indicate if the resident received one of the therapeutic options for the current COVID-19 event.
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A Therapeutic is defined as a treatment, therapy, or drug. Monoclonal antibodies are examples of anti-SARS-CoV-2 antibody-based therapeutics used to help the immune system recognize and respond more effectively to the COVID-19 virus.
Required. Select “Did not receive,” if the resident has not received monoclonal antibody therapy.
If the resident received a monoclonal antibody therapeutic, select the appropriate therapeutic that was administered to the resident. Select “YES,” if the resident was treated with in-house stock that was stored at your facility (specifically, either administered by your LTCF or by an outside entity using stock provided by your LTCF). If the resident was not treated with in-house stock, select “NO.”
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*Hospitalization (Transferred to an acute care facility) |
Required. Select “YES,” if the resident was transferred to an acute care facility (hospital, long-term acute care hospital, or acute inpatient rehabilitation facility only) for this COVID-19 event, otherwise select “NO.” Notes:
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*COVID-19 Death Indicate if the resident died from COVID-19 related complications while in the facility or another location. |
COVID-19 Deaths: Defined by NHSN as residents who died from SARS-CoV-2 (COVID-19) related complications and includes resident deaths in the facility AND in other locations, such as an acute care facility, in which the resident with COVID-19 was transferred to receive treatment. Required. Select “YES” if the resident identified with a newly positive COVID-19 viral test result, had signs and/or symptoms of COVID-19 as defined by the CDC, was on transmission-based precautions for COVID-19, or died from ongoing complications related to a previous COVID-19 infection. Select “NO,” if the resident did not die, or if the resident’s death was not related to COVID-19 or a COVID-19 related complication.
Notes:
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | State Veterans Home TOI - Resident |
Subject | NHSN State Veterans Homes COVID-19 |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2024-10-31 |