OMB Approved
O MB No. 0920-1290
Exp. Date 09/30/2020
www.cdc.gov/nhsn
COVID-19 Module
Long Term Care Facility: Resident Impact and Facility Capacity
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NHSN Facility ID: |
CMS Certification Number (CCN): |
Facility Name: |
*Date for which responses are reported: ________/________/________ |
For the following questions, report data on the same day each week at least once a week. For questions requiring counts, include only new data since the last date the counts were collected for reporting in the NHSN Module.
Facility Capacity and SARS-CoV-2 Testing |
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ALL BEDS (FIRST SURVEY ONLY) |
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CURRENT CENSUS: Total number of beds that are currently occupied |
RESIDENTS |
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TESTING: Does the LTCF have the ability to perform or to obtain resources for performing COVID-19 viral testing (nucleic acid or antigen) on all current residents within the next 7 days, if needed? □ YES □ NO
If NO, indicate reason(s) below (select all that apply):
Continued >> |
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 25 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-XXXX).
CDC 57.144 (Front) V.3 (8-2020) |
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Facility Capacity and SARS-CoV-2 Testing |
Facility Capacity and SARS-CoV-2 Testing |
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RESIDENTS |
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During the past two weeks, on average how long did it take your LTCF to receive COVID-19 viral (nucleic acid or antigen) test results of residents? (Check one) |
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Since the last date of data entry in the Module, has your LTCF performed COVID-19 viral testing on residents? □ YES □ NO
If YES, indicate the reason COVID-19 testing was performed (Check all that apply):
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STAFF AND PERSONNEL Includes anyone working or volunteering in the facility, such as contractors, temporary staff, resident care givers, shared staff, etc. |
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TESTING Does the LTCF have the ability to perform or to obtain resources for performing COVID-19 viral testing (nucleic acid or antigen) on all staff and/or facility personnel within the next 7 days, if needed? □ YES □ NO
If NO, indicate reason(s) below (Check all that apply):
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On average, how long does it take your LTCF to receive COVID-19 viral (nucleic acid or antigen) test results of staff and/or facility personnel? (Check one)
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Since the last date of data entry in the Module, has your LTCF performed COVID-19 viral testing on staff and/or facility personnel? □ YES □ NO
If YES, indicate the reason for COVID-19 testing was performed (Check all that apply):
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | COVID-19 Form Resident Impact and Facility Capacity |
Subject | NHSN LTCF COVID-19 |
Author | CDC/NCEZID/DHQP |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |