Form 0920 Annual Hospital Interview (revised)

Attachment A: 2020 Annual Hospital Interview (Revised)

Form Approved

OMB No. 0920-0212

Exp. date XX/XX/XXXX

Notice – CDC estimates the average public reporting burden for this collection of information as 120 minutes, 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, MS D-74, Atlanta, GA 30333; ATTN: PRA (0920-0212).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42U.S.C. 242m) and the Confidential Information Protection and Statistical Efficiency Act (Title III of the Foundations for Evidence-Based Policymaking Act of 2018 (Pub. L. No. 115-435, 132 Stat. 5529 § 302)). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

Part 1. Hospital Utilization Statistics

1. What is the number of currently staffed inpatient beds in this hospital, not including “newborn” bassinets?

a) Total staffed inpatient beds: ________________

b) If you submit data combined with other hospital(s), what is the number of currently staffed inpatient beds, not including “newborn” bassinets, for all the hospitals that report together?

Combined total staffed inpatient beds: _______________

2. What was the average length of stay (in days) for inpatients in this hospital in calendar year 2020?

______________________________

Part 2. General Questions

3. What is the primary service type of this hospital?

• General acute care

• Specialty acute care hospital (e.g., surgical, maternity, cancer, heart, ENT, orthopedic, etc…)

• Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)

• Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)

• Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)

4. Was this hospital open for the full calendar year 2020?

• Yes

• No Please provide the dates the hospital was open for inpatient service in 2020: ______________________________________________

• Never open in 2020

5. In the past year, has this hospital merged with or separated from another hospital?

• Merger  Please continue with item 5a below.

• Separation Please continue with item 5a below.

• Neither Please proceed to item 7.

5a. Please provide the name(s) and address(es) of the other hospital(s) involved:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

6. What is the primary service type(s) of the other hospital(s) involved? Check all that apply.

• General acute care

• Specialty hospital (e.g. surgical, maternity, cancer, heart, ENT, orthopedic, etc…)

• Children’s hospital (including general, orthopedic, ENT, cancer, heart, and other acute care)

• Psychiatric hospital (including children’s psychiatric and alcohol/chemical dependency)

• Long term acute care (including adult and children’s rehabilitation, chronic disease, TB)

7. In calendar year 2020, did your facility have any significant changes to the total number of inpatient beds?

• Yes  Please explain_____________________________________________

• No

8. Do you anticipate any significant changes in your discharge volume in the coming year (for example, opening a cardiac wing or closing a birthing center)?

• Yes  Please explain_____________________________________________

• No

Part 3. Data Reporting

9. When this hospital reports data to the State or to the hospital association, is the information solely for this hospital or are other hospital(s) included in the data submission?

• Solely for this hospital

• Combined with other hospital(s)  Please provide the name(s) of the other hospital(s):

__________________________________________________________________

__________________________________________________________________

10. Do the data you provide to us include records from your hospital only?

• Yes  Please proceed to item 11 below.

• No  Please continue with item 10a below.

• Don’t know

10a. Is it possible to identify the records from your hospital separate from the other hospital(s) that report with you?

 Yes  No  Don’t know

11. Do the inpatient data you send to us include records for all discharges (including those paying with public or private insurance as well as self-pay, charity, workmen’s compensation, and court or law enforcement)?

 Yes  No (skip to 11b)

11a. If yes, how many (or approximately what percent) of the records you sent us for the calendar year 2020 were paid with public or private insurance (excluding workmen’s compensation)?

___________________________

11b. If no, then approximately what number or percent of total records (including those for records not submitted) for the calendar year 2020 were for other forms of payment (self-pay, charity, workmen’s compensation, and/or court or law enforcement)?

___________________________

12. Do the ambulatory data you send to us include records for all visits (including those paying with public or private insurance as well as self-pay, charity, workmen’s compensation, and court or law enforcement)?

 Yes  No (skip to 12b)

12a. If yes, how many (or approximately what percent) of the records you sent us for the calendar year 2020 were for visits paid with public or private insurance (excluding workmen’s compensation)?

___________________________

12b. If no, then approximately what number or percent of total claims (including those for records not submitted) for the calendar year 2020 were for other forms of payment (self-pay, charity, workmen’s compensation, and/or court or law enforcement)?

___________________________

13. Please provide the counts or estimates for ED visits by quarter or year for calendar year 2020 for the following categories.

If you cannot separate ED visits from all Outpatient visits, please check here. 

Number of ED VISITS for:	Annual	Quarter 1	Quarter 2	Quarter 3	Quarter 4
All visits made to ED
Insured patients (public and private, exclude workmen’s compensation)
All other forms of payment (self-pay, charity, court/law enforcement)

14. Please provide the counts or estimates for OPD visits by quarter or year for calendar year 2020 for the following categories.

If you cannot separate OPD visits from all Outpatient visits, please check here. 

Number of OPD VISITS for:	Annual	Quarter 1	Quarter 2	Quarter 3	Quarter 4
All visits made to OPD
Insured patients (public and private, exclude workmen’s compensation)
All other forms of payment (self-pay, charity, court/law enforcement)

15. In calendar year 2020, does your hospital have a birthing unit or offer obstetric services for females with deliveries?

 Yes  No

15a. Please provide the total number of inpatient discharges (including live births) or the total number of admissions (and live births) by month or annually for calendar year 2020.

	Total number of inpatient discharges (including live births)		Total number of admissions		Total Number of Live births
Annual		OR		AND
January		OR		AND
February		OR		AND
March		OR		AND
April		OR		AND
May		OR		AND
June		OR		AND
July		OR		AND
August		OR		AND
September		OR		AND
October		OR		AND
November		OR		AND
December		OR		AND

Part 4. COVID-19 QUESTIONS:

1. In the past year, did your hospital experience shortages of coronavirus disease (COVID-19) tests for any patients with presumptive positive COVID-19 infection?

• Never

• Some of the time

• Most of the time

• All of the time

• Not applicable – did not need to do any COVID-19 testing

• Don’t know

2. In the past year, did your hospital create areas outside the hospital entrance to screen patients for coronavirus disease (COVID-19) infection?

• Yes

• No

• Don’t know

3. In the past year, did your hospital need to turn away or refer elsewhere any patients with confirmed or presumptive positive coronavirus disease (COVID-19) infection?

• No COVID-19 patients were turned away or referred elsewhere

• Some COVID-19 patients were turned away or referred elsewhere

• Most COVID-19 patients were turned away or referred elsewhere

• All COVID-19 patients were turned away or referred elsewhere

• Not applicable – the emergency department did not have any COVID-19 patients

• Don’t know

4. In the past year, did any of the following clinical care providers in your hospital test positive for coronavirus disease (COVID-19) infection?

   1. Physicians

• Yes

• No

• Not applicable – did not have such provider type onsite

• Don’t know

2. Physician assistants

• Yes

• No

• Not applicable – did not have such provider type onsite

• Don’t know

3. Nurse practitioners

• Yes

• No

• Not applicable – did not have such provider type onsite

• Don’t know

4. Certified nurse-midwives

• Yes

• No

• Not applicable – did not have such provider type onsite

• Don’t know

5. Registered nurses/licensed practical nurses

• Yes

• No

• Not applicable – did not have such provider type onsite

• Don’t know

6. Other clinical care providers

• Yes (please specify: ________________________________)

• No

• Not applicable – did not have such provider type onsite

• Don’t know

5. For calendar year 2020, how many inpatient/ED visits at your hospital were related to CONFIRMED coronavirus disease (COVID-19) infections, by quarter or by year? Fill in the grid below.

6. For calendar year 2020, how many inpatient/ED visits at your hospital were related to PRESUMPTIVE POSITIVE coronavirus disease (COVID-19) infections, by quarter or by year? Fill in the grid below.

Number of inpatient/ED visits for:	Annual	Quarter 1	Quarter 2	Quarter 3	Quarter 4
Confirmed COVID-19 visits
Presumptive Positive COVID-19 visits

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