Dialysis COVID-19 Outpatient Form

OMB Approved

OMB No. 0920-1306

Exp. Date 11/30/2020

www.cdc.gov/nhsn

COVID–19 Module

Dialysis Outpatient Facility

*required to save as complete

**conditionally required

Facility Operational Information For the following questions, please collect data at the same time (for example, 7 AM)
_________	*Facility ID (OrgID)
_________	*CMS Certification Number (CCN)
_________	*Facility Name
___/____/_____	*Date for which responses are reported
_________	*In-center Patient Census
_________	*Home Patient Census
_________	*Total Certified Stations
_________	*Isolation Stations Included in Total Certified Stations
 Yes  No	*Is your facility a designated COVID unit?
 Yes  No	*Does your facility have designated COVID shifts?
_________	How many patients on the current in-center census reside in nursing homes?
_________	How many patients on the current home census reside in nursing homes?

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.

SARS-CoV-2 Positive (+) Patients and Staff
_________	*Number of newly confirmed in-center patients since last reporting
_________	*Number of newly confirmed in-center patients since last reporting that reside in nursing homes
_________	*Number of newly confirmed patients since last reporting that are home patients
_________	*Number of newly confirmed staff since last reporting
_________	*Number of SARS-CoV-2 patients who are currently admitted to the hospital
_________	*Number of confirmed patients currently self-monitoring and continuing in-center therapy
_________	*Number of confirmed patients currently self-monitoring and continuing home therapy

Suspected SARS-CoV-2 Infection
_________	*Number of new suspect patient cases since last reporting
_________	*Number of new suspect staff cases since last reporting

Testing for SARS-CoV-2 Infection
_________	*Number of new patients who were recently tested for SARS-CoV-2 since last reporting
_________	*Of those new patients who were recently tested for SARS-CoV-2 since last reporting, how may had a negative SARS-CoV-2 test result since last reporting
_________	*Of those new patients who were recently tested for SARS-CoV-2 since last reporting, how may had a positive SARS-CoV-2 test result since last reporting
_________	*Of those new patients who were recently tested for SARS-CoV-2 since last reporting, how may had an unknown SARS-CoV-2 test result since last reporting

SARS-CoV-2 Positives (+) that have recovered
_________	*Number of patients recovered since last reporting
_________	*Number of staff recovered since last reporting

Suspected or Confirmed SARS-CoV-2 deaths
_________	*Number of patients with suspected or confirmed SARS-CoV-2 infection that have died since last reporting
_________	*Number of staff with suspected or confirmed SARS-CoV-2 infection that have died since last reporting

For the following questions, please collect data at the same time at least once a week (for example, 7 AM)

Staff and/or Personnel Impact
Will your facility have a critical shortage of staff and/or personnel within the next week?
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	Tech: dialysis technician
 Yes  No	Other staff or facility personnel, regardless of clinical responsibility or patient contact not included in the categories above (for example, environmental services, biomed)

Supplies & Personal Protective Equipment (PPE)
Supply Item	Do you currently have any supply?	Do you have enough for one week if using conventional strategies?
N95 masks	 Yes  No	 Yes  No
Surgical masks or medical facemasks	 Yes  No	 Yes  No
Eye protection, including face shields or goggles	 Yes  No	 Yes  No
Single-use Isolation Gowns	 Yes  No	 Yes  No
Gloves	 Yes  No	 Yes  No
Alcohol-based hand sanitizer	 Yes  No	 Yes  No

Laboratory Testing
 Yes  No	Does your facility have the ability to collect specimens onsite for SARS-CoV-2 testing?
 Viral (PCR)  Antigen  Antibody	**If yes, what types of specimens are being collected?
 NP swab  Anterior Nares swab  Mid Turbinate swab  OP swab  Saliva	**If yes to viral (PCR) tests, what types of specimens are being collected?
Lack of recommended personal protective equipment (PPE) for personnel to wear during specimen collection Lack of supplies for specimen collection Lack of access to a laboratory for submitting specimens Lack of access to trained personnel to perform testing Uncertainty about testing reimbursement Other: Specify__________________________	**If no, indicate reasons why specimens are not being collected onsite for SARS-CoV-2 testing?
 Yes  No	If yes, does your facility have an in-house point-of-care test machine (capability to perform SARS-CoV-2 testing within your facility)?