Form CDC 57.144 CDC 57.144 Resident Impact and Facility Capacity

OMB Approved

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Resident Impact and Facility Capacity

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)

Resident Impact

__________	ADMISSIONS: Residents admitted or readmitted who were previously diagnosed with COVID-19 from another facility
__________	CONFIRMED: Residents with new laboratory positive COVID-19
__________	SUSPECTED: Residents with new suspected COVID-19
__________	TOTAL DEATHS: Residents who have died in the facility or another location
__________	COVID-19 DEATHS: Residents with suspected or laboratory positive COVID-19 who died in the facility or another location

Facility Capacity and Laboratory Testing

_________	ALL BEDS (FIRST SURVEY ONLY)
_________	CURRENT CENSUS: Total number of beds that are currently occupied
	*TESTING: Does your facility have access to COVID-19 testing while the resident is in the facility? □ YES □ NO If YES, what laboratory type? Select all that apply. □ State health department lab □ Private lab (hospital, corporation, academic institution) □ Other
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 40 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 57.144 (Front) V.2 (6-2020)

*Required for Saving