Form CDC 57.146 CDC 57.146 Supplies & Personal Protective Equipment

OMB Approved

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Supplies and Personal Protective Equipment

NHSN Facility ID:

CMS Certification Number (CCN):

Facility Name:

*Date for which responses are reported: ________/________/________

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

Supply Item	Do you currently have any supply?	Do you have enough for one week?
N95 masks	□ YES □ NO	□ YES □ NO
Surgical masks	□ YES □ NO	□ YES □ NO
Eye protection, including face shields or goggles	□ YES □ NO	□ YES □ NO
Gowns	□ YES □ NO	□ YES □ NO
Gloves	□ YES □ NO	□ YES □ NO
Alcohol-based hand sanitizer	□ YES □ NO	□ YES □ NO
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 15 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 57.146 (Front) v.2

*Required for Saving