Form 0920-1290 COVID-19 Module - LTCF Staff and Personnel Impact Form (

Long-term Care Facility Component

Instructions for Completion of the COVID-19 Long-term Care Facility (LTCF): Staff and Personnel Impact Form (CDC 57.145)

Data Field	Instructions for Data Collection
NHSN Facility ID #	The NHSN-assigned facility ID will be auto-entered by the computer.
CMS Certification Number (CCN)	Auto-generated by the computer if the facility has previously entered the CCN number during NHSN registration. See NHSN CCN Guidance document for instructions on how to add a new CCN or edit an entered CCN.
Facility Name	Auto-generated by the computer if the facility has previously entered facility name during registration.
Date for which “staff and personnel Impact” responses are reported	Required. Select the date on the calendar for which the responses are being reported in the NHSN COVID 19-Module.

Important:

While daily reporting will provide the timeliest data to assist with COVID-19 emergency response efforts, retrospective reporting of prior day(s), unless otherwise specified, is encouraged if daily reporting is not feasible. At a minimum, facilities should report data at least once per week.

Data Field	Instructions for Data Collection
CONFIRMED COVID-19 Staff and facility personnel with new laboratory-positive COVID-19	If this is the first time Confirmed COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module, facilities are required to: Enter the total number of staff and facility personnel who have been identified with laboratory positive COVID-19 this week. Please follow instructions in #3 for subsequent data entries. Facilities are encouraged, but not required, to enter Confirmed COVID-19 counts since January 1, 2020: At any time, facilities may enter the total number of staff and facility personnel who have been identified with laboratory positive COVID-19 since January 1, 2020. Please follow instructions in #3 for subsequent data entries. If this is not the first time Confirmed COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Since the last date that Confirmed COVID-19 counts (laboratory positive COVID-19 test results) were entered for staff and facility personnel, enter the number of staff and facility personnel who have newly been identified as having a laboratory positive COVID-19 test result Note: Include only new laboratory positive test COVID-19 test results among staff and facility personnel since the last time these counts were entered in the Module.  Note: Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
SUSPECTED COVID-19 Staff and facility personnel with new suspected COVID-19	If this is the first time Suspected COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module, facilities are required to: Enter the number of staff and facility personnel who have been or are being managed as though they have COVID-19, but do not have a laboratory positive COVID-19 test result this week. Please follow instructions in #3 for subsequent data entries. Facilities are encouraged, but not required, to enter Suspected COVID-19 counts for staff and facility personnel since January 1, 2020: At any time, facilities may enter the number of staff and facility personnel who have been or are being managed as though they have COVID-19, but do not have a laboratory positive COVID-19 test result since January 1, 2020. Please follow instructions in #3 for subsequent data entries. If this is not the first time Suspected COVID-19 counts for staff and facility personnel are being entered in the NHSN COVID-19 Module: Since the last date that Suspected COVID-19 counts for staff and facility personnel were entered in the Module, enter the number of staff and facility personnel who have been or are being newly managed as though they have COVID-19 (but do not have a laboratory positive COVID-19 test result). Notes: Suspected is defined as residents being managed or treated with the same precautions as those with a laboratory positive COVID-19 test result but have not been tested or have pending test results. Staff and facility personnel with a laboratory negative COVID-19 test result, but whom continue to be managed or treated with the same precautions as laboratory positive COVID-19 staff and facility personnel because of exposure and/or suggestive signs and symptoms should be included in this count. Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
COVID-19 DEATHS Staff and facility personnel with new suspected or laboratory-positive COVID-19 who died	If this is the first time the COVID-19 Deaths count for staff and facility personnel is being entered in the NHSN COVID-19 Module, facilities are required to: Enter the total number of deaths this week for staff and facility personnel with suspected PLUS those deaths this week for staff and facility personnel with confirmed (laboratory-positive COVID-19 test result) COVID-19. Please follow instructions in #3 for subsequent data entries. Facilities are encouraged, but not required, to enter COVID-19 Deaths since January 1, 2020: At any time, facilities may enter the total number of deaths for staff and facility personnel with suspected PLUS those deaths for staff and facility personnel with confirmed (laboratory-positive COVID-19 test result) COVID-19 since January 1, 2020. Please follow instructions in #3 for subsequent data entries. If this is not the first time the COVID-19 Deaths count for staff and facility personnel is being entered in the NHSN COVID-19 Module: Enter the total number of new deaths for staff and facility personnel with suspected or laboratory positive COVID-19 that have occurred since the last date the COVID-19 Death count for staff and facility personnel was entered. Note: Include only new deaths since the last time these counts were entered in the Module. Notes: Suspected is defined as residents being managed or treated with the same precautions as those with a laboratory positive COVID-19 test result but have not been tested or have pending test results. Staff and facility personnel with a laboratory negative COVID-19 test result, but whom continue to be managed or treated with the same precautions as laboratory positive COVID-19 staff and facility personnel because of exposure and/or suggestive signs and symptoms should be included in this count. Staff and facility personnel include anyone working or volunteering in the facility, which includes, but not limited to contractors, temporary staff, resident care givers, shared staff, etc.
STAFFING SHORTAGE Does your organization have a shortage of staff and/or personnel? Select “YES” or “NO” for each group. (Select one answer for each group)	On the date responses are reported in in the Module, has your facility identified a shortage of staff and/or facility personnel in any of the following staff and facility personnel groups? Note: Each facility should identify staffing shortages based on their facility needs and internal policies for staffing ratios. Select “YES” for each group in which there is currently a staff shortage OR “NO” for each group in which there is not currently a staff shortage: (Select one answer for each group) Nursing Staff: registered nurse, licensed practical nurse, or vocational nurse. Clinical Staff: physician, physician assistant, or advanced practice nurse. Aide: certified nursing assistant, nurse aide, medication aide, or medication technician. Other staff or facility personnel: that are not included the above categories, regardless of clinical responsibility or resident contact. These personnel may include, but are not limited to environmental services, cook, dietary, pharmacists, pharmacy techs, activities director, care givers, wound care, physical therapy, shared staff, etc.

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