Form 0920-20LW Dialysis Component

OMB Approved

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID–19 Module

Dialysis Outpatient Facility

Facility Operational Information

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____________

Is your facility a designated COVID unit?_________

If no, does your facility have designated COVID shifts?________

How many patients on the current in-center census reside in long-term care facilities (LTCFs)?

How many patients on the current home census reside in LTCFs?

COVID–19 Positive (+) Patients and Staff

Number of newly-confirmed patients since last reporting________

Number of newly-confirmed patients since last reporting that reside in LTCFs ________

Number of newly-confirmed patients since last reporting that are home patients ________

Number of newly-confirmed staff since last reporting___________

Number of confirmed patients currently admitted to hospital/receiving treatment in hospital _______

Number of confirmed patients currently self-monitoring and continuing in-center therapy _______

Number of confirmed patients currently self-monitoring and continuing home therapy _________

Patients Under Investigation (PUI) *Only Identify persons being tested for COVID-19*

Number of new PUIs since last reporting_______

Number of new PUIs that reside in LTCFs since last reporting ______
Number of new Staff under investigation since last reporting_________

Tested Negative (-) for COVID-19

Number of Patients newly tested negative since last reporting ______
Number of Staff newly tested negative since last reporting_________

COVID–19 Positives (+) that have recovered

Number of Patients recovered since last reporting_____

Number of new Staff recovered since last reporting _______

COVID– 19 Positive (+) Deaths

Number of new Patient deaths with COIVD-19 since last reporting______

Number of new Staff deaths with COVID-19 since last reporting_________

Staff and/or Personnel Impact
Will your facility have a 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 resident 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?
N95 filtering facepiece respirators	 Yes  No	 Yes  No
Facemasks	 Yes  No	 Yes  No
Eye protection, including face shields or goggles	 Yes  No	 Yes  No
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 onsite testing for COVID-19?
 Viral (PCR)  Antigen  Antibody	If yes, what types of tests are being performed?
 NP swab  Anterior Nares  Mid Turbinate  OP swab  Saliva	If yes to viral (PCR) tests, what types are being performed?

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 20 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 (0920-1290)

CDC.