Form 57.145 Staff and Personnel Impact form (57.145)

O MB Approved

OMB No. 0920-1306

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Staff and Personnel Impact

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NHSN Facility ID: CMS Certification Number (CCN):

Facility Name:

*Date for which responses are being reported: _____/______/_____ Date Last Modified: _____/______/______

Counts should be reported on the correct calendar day and include only new counts for the calendar day (specifically, since counts were last collected). If the count is zero, a “0” must be entered as the response. A blank response is equivalent to missing data. NON-count questions should be answered one calendar day during the reporting week.

Staff and Personnel Impact
	CONFIRMED: Number of staff and facility personnel with a new positive COVID-19 viral test result, either from a NAAT (PCR) or antigen test.
	TEST TYPE: Of the number of reported Confirmed COVID-19 staff and facility personnel, how many had the following: _____Positive SARS-CoV-2 antigen test only [no other testing performed] _____Positive SARS-CoV-2 NAAT (PCR) [no other testing performed] _____±Positive SARS-CoV-2 antigen test and negative SARS-CoV-2 NAAT (PCR) _____±Any other combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s) with at least one positive test ± Only include if the two tests were performed within 2 days of each other. Otherwise, count first test only.
	_____RE-INFECTIONS: **Of the number of reported Confirmed staff and facility personnel, how many were considered as re-infected? ­­_____SYMPTOMATIC: Of the number of reported staff and facility personnel with Re-Infections, how many had signs and/or symptoms consistent with COVID-19? _____ASYMPTOMATIC: Of the number of reported staff and facility personnel with Re-Infections, how many did not have signs and/or symptoms consistent with COVID-19?
	COVID-19 DEATHS: Number of staff and facility personnel with COVID-19 who died.

Staff and Personnel Impact for Non-COVID-19 (SARS-CoV-2) Respiratory Illness
	CONFIRMED INFLUENZA: Number of staff and facility personnel with a new positive influenza (flu) test result.
	RESPIRATORY ILLNESS: Number of staff and facility personnel with acute respiratory illness symptoms, excluding confirmed COVID-19 and/or influenza (flu).
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 57.145 (Front)

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Staff and Personnel Impact for Co-Infections
	CONFIRMED INFLUENZA and COVID-19: Number of staff and facility personnel with a confirmed co-infection with influenza (flu) and SARS-CoV-2 (COVID-19).

Does your organization have a shortage of staff and/or personnel?
Staffing Shortage?	Staff and Personnel Groups
YES NO	Nursing Staff: registered nurse, licensed practical nurse, vocational nurse
YES NO	Clinical Staff: physician, physician assistant, advanced practice nurse
YES NO	Aide: certified nursing assistant, nurse aide, medication aide, and medication technician
YES NO	Other staff or facility personnel, regardless of clinical responsibility or resident contact not included in the categories above (for example, environmental services)