Form CDC 57.145 CDC 57.145 Staff and Personnel Impact

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Staff and Personnel Impact

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)

_________	CONFIRMED: Staff and facility personnel with new laboratory positive COVID-19
_________	SUSPECTED: Staff and facility personnel with new suspected COVID-19 who are being managed as though they have it
_________	COVID-19 DEATHS: Staff and facility personnel with new suspected or laboratory positive COVID-19 who died
Does your organization have a shortage of staff and/or personnel?
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	Aide: certified nursing assistant, nurse aide, medication aide, and medication 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)
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 57.145 (Front)

*Required for saving