CDC 57.146 COVID-19 Module - LTCF: Supplies and Personal Protective

OMB Approved OMB No. 0920-1317

Exp. Date 01/31/2024 www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Supplies and Personal Protective Equipment

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NHSN Facility ID: CMS Certification Number (CCN):

Facility Name: Facility Type:

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

For the following questions, please collect and report responses once during the reporting week.

Infection Control Supply Item	Availability	Urgent Need: Indicate if facility will no longer have the ABHR in 7 days
Alcohol-based hand rub (ABHR)	Available for use: ⎕YES ⎕NO	⎕YES ⎕NO
Personal Protective Equipment (PPE) Supply Item	Facility ±strategy for optimizing the selected supply item (select one)	Urgent Need: Indicate if facility will no longer have the supply item in 7 days
N95 Respirator	⎕Conventional; ⎕Contingency; ⎕Crisis	⎕YES ⎕NO
Face mask	⎕Conventional; ⎕Contingency; ⎕Crisis	⎕YES ⎕NO
Eye Protection, including goggles or face shields	⎕Conventional; ⎕Contingency; ⎕Crisis	⎕YES ⎕NO
Gowns	⎕Conventional; ⎕Contingency; ⎕Crisis	⎕ YES ⎕NO
Gloves	⎕Conventional; ⎕Contingency; ⎕Crisis	⎕YES ⎕NO
±Conventional: recommended strategies as part of infection prevention and control ±Contingency: strategies used during periods of anticipated PPE shortages ±Crisis: strategies used when supplies cannot meet facility’s current PPE needs
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 (0920-1317). CDC 57.146 (Front) v.3 February 2021

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Need for Government Support or Assistance
The information collected below will be shared with federal, state, and local partners to identify COVID-19 emergency response needs more rapidly. However, facilities should also continue to report urgent needs through established state and local reporting mechanisms—particularly in cases where those needs present immediate threats to the health and safety of residents or staff. For the following questions, please report responses once during the reporting week.
	Would your facility like outreach by local and/or state government for assistance with any of the items below?±
Staffing Shortages	⎕YES    ⎕NO
Personal Protective Equipment Shortages	⎕YES    ⎕NO
SARS-CoV-2 (COVID-19) Testing Supply Shortages	⎕YES    ⎕NO
Infection Control/ Outbreak Management	⎕YES    ⎕NO
Staff Training	⎕YES    ⎕NO
COVID-19 Vaccination (Residents and/or Staff)	⎕YES    ⎕NO

±Providing this information does not guarantee resources can be provided as local, state, and federal resources are allocated based on supply and priority of need.