Aging and Long-Term Support Administration

COVID-19 Facility Survey

Facility Information

Please verify your facility by entering your facility type, license/certification number and date of license/certification.. Instructions.

 

 

Last updated on:

DSHS Indicates information requested by DSHS

NHSN Indicates information that will be submitted to NHSN

Residents/Clients

Types of Resident Testing Performed

Type should equal number of Positive Tests. Of the number of positive tests reported above, how many tested used each of the following:

For positives using SARS-CoV-2 Antigen Test only, indicate how many received COVID-19 vaccinations at least 14 days prior to the test:

For positives using SARS-CoV-2 NAAT (PCR) Test only, indicate how many received COVID-19 vaccinations at least 14 days prior to the test:

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For positives using any Combination of Tests, indicate how many received COVID-19 vaccinations at least 14 days prior to the test.

Types of Resident/Client Re-Infections

Resident Therapeutics

Facility Staff

Types of Staff Testing Performed

Type should equal number of Positive Tests. Of the number of positive tests reported above, how many tested used each of the following:

Types of Staff Re-Infections

Testing Capability

Please Specify the POC Equipment Brand(s) Used in Your Facility:

Supplies and Personal Protective Equipment

Ventilators

Need for Government Support or Assistance

Would your facility like outreach by local and/or state government for assistance with any of the items below?
Notice: 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.

Problems completing this form? Call 1-888-856-5691 or email RCSPolicy@dshs.wa.gov