COVID-19 Facility Survey

Facility Information

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

Facility type:
License/Certification #:
License/Cert. Date:

Last updated on:

Phone Contact
Phone number to call if we have any questions.

County (Required)
County that the facility is located in.

Submit to NHSN
Select Yes to give DOH permission to submit additional survey questions to NHSN.

DSHS Indicates information requested by DSHS

NHSN Indicates information that will be submitted to NHSN

Residents/Clients

Number of Licensed Beds

Current Resident/Client Count (Required, 0 - ) DSHS NHSN
Total number of residents/clients currently in the facility.

Current Number of Confirmed Cases among Residents/Clients (0 - ) DSHS
Current number of confirmed COVID-19 residents/clients in the facility. Do not include staff.

Number of New Positive Tests among Residents/Clients Since (0 - ) NHSN
Number of new Positive COVID-19 viral test results in the facility since your last report. Do not include staff.

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:

Number of Positives Using SARS-CoV-2 Antigen Test Only
Number of residents who tested positive using SARS-CoV-2 antigen test only (no other testing performed). Do not include staff.

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

Not vaccinated with COVID-19 vaccine

Only dose 1 of Pfizer-BioNTech COVID-19 vaccine

Dose 1 and dose 2 of Pfizer-BioNTech COVID-19 vaccine

Only 1 dose of Moderna COVID-19 vaccine

Dose 1 and dose 2 of Moderna COVID-19 vaccinee

Dose of Janssen COVID-19 vaccine

Complete COVID-19 vaccination series from an unspecified manufacturer

Number of Positives Using SARS-CoV-2 NAAT (PCR) Test Only
Number of residents who tested positive using SARS-CoV-2 NAAT (PCR) test only (no other testing performed). Do not include staff.

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:

Not vaccinated with COVID-19 vaccine

Only dose 1 of Pfizer-BioNTech COVID-19 vaccine

Dose 1 and dose 2 of Pfizer-BioNTech COVID-19 vaccine

Only dose 1 of Moderna COVID-19 vaccine

Dose 1 and dose 2 of Moderna COVID-19 vaccine

Dose of Janssen COVID-19 vaccine

Complete COVID-19 vaccination series from an unspecified manufacturer

Number of Positives Using SARS-CoV-2 Test and Negative SARS CoV-2 NAAT (PCR) Test
Number of residents who tested positive using SARS-CoV-2 antigen test and negative SARS CoV-2 NAAT (PCR). Only include if the two tests performed within 2 days of each other. Do not include staff.

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Number of Positives Using any Combination of Tests
Number of residents who tested positive using any combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s). Only include if the two tests performed within 2 days of each other. Do not include staff.

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

Not vaccinated with COVID-19 vaccine

Only dose 1 of Pfizer-BioNTech COVID-19 vaccine

Dose 1 and dose 2 of Pfizer-BioNTech COVID-19 vaccine

Only dose 1 of Moderna COVID-19 vaccine

Dose 1 and dose 2 of Moderna COVID-19 vaccine

Dose of Janssen COVID-19 vaccine

Complete COVID-19 vaccination series from an unspecified manufacturer

Number of Re-Infections among Residents/Clients Since (0 - 0) NHSN
Of the 0 reported residents above with a positive test result, how many were considered as re-infected? Do not include staff.

Types of Resident/Client Re-Infections

Number of Symptomatic Re-Infections among Residents/Clients
Of the 0 reported resident(s) with re-infections, how many had signs and/or symptoms consistent with COVID-19? Do not include staff.

Number of Asymptomatic Re-Infections among Residents/Clients
Of the 0 reported resident(s) with re-infections, how many did not have signs and/or symptoms consistent with COVID-19? Do not include staff.

Current Number of Suspected Cases among Residents/Clients (0 - ) DSHS
Current number of suspected COVID-19 (showing symptoms, but not officially diagnosed) residents/clients in the facility. Do not include staff.

Number of Residents/Clients Currently Hospitalized (0 - ) DSHS
Number of residents/clients in your facility who are CURRENTLY hospitalized due to COVID-19. Do not include staff.

Number of Residents Admitted to the Facility from Another Facility Since (0 - 2000) NHSN
Number of new admitted or re-admitted residents from another facility who were previously diagnosed with COVID-19 since your last report. Do not include staff.

Current Number of Influenza Cases among Residents/Clients Since (0 - ) NHSN
Number of residents with new influenza (flu) since your last report. Do not include staff.

Current Number of Influenza with COVID-19 Cases among Residents/Clients Since (0 - ) NHSN
Number of residents with BOTH influenza (flu) AND COVID-19 since your last report. Do not include staff.

Current Number of Other Respiratory Illnesses among Residents/Clients Since (0 - ) NHSN
Number of residents with acute respiratory illness symptoms, NOT COVID-19 and/or influenza (flu) since your last report. Do not include staff.

Total Number of Resident/Client Deaths from COVID-19 (0 - 10000) DSHS
Total number of residents/clients deaths due to COVID-19. Do not include staff.

Number of New Deaths among Residents/Clients for Any Reason Since (0 - 10000) NHSN
Number of new resident deaths for ANY reason since your last report, include BOTH COVID-19 AND non-COVID-19 related deaths. Do not include staff.

Number of New Deaths among Residents/Clients from COVID-19 Since (0 - ) NHSN
Number of new reported residents/clients deaths due to COVID-19 since your last report. Do not include staff.

Can the Facility Test Residents Within the Next 7 Days if Needed? NHSN
Does your facility have the ability to perform or to obtain resources for performing COVID-19 viral testing on all current residents within the next 7 days, if needed?

Resident Therapeutics

Number of Bamlanivimab Administered from Facility Stock NHSN
How many residents were treated with Bamlanivimab from stock stored at this facility.

Number of Bamlanivimab Administered from Other Stock NHSN
How many residents were treated with Bamlanivimab Therapeutics from stock that was stored at another facility, such as an infusion center?

Number of Casirivimab plus Imdevimab (Regeneron) Administered from Facility Stock NHSN
How many residents were treated with Casirivimab plus Imdevimab (Regeneron) from stock stored at this facility.

Number of Casirivimab plus Imdevimab (Regeneron) Administered from Other Stock NHSN
How many residents were treated with Casirivimab plus Imdevimab (Regeneron) from stock that was stored at another facility, such as an infusion center?

Number of Bamlanivimab/Etesevimab (Lilly) Administered from Facility Stock NHSN
How many residents were treated with Bamlanivimab/Etesevimab (Lilly) from stock stored at this facility.

Number of Bamlanivimab/Etesevimab (Lilly) Administered from Other Stock NHSN
How many residents were treated with Bamlanivimab/Etesevimab (Lilly)) from stock that was stored at another facility, such as an infusion center?

Facility Staff

Staff Count DSHS
Total number of staff, including those not currently at work.

Number of New Positive Tests among Staff Since (0 - 1000) NHSN
New Number of staff with positive COVID-19 viral test result since your last report.

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:

Number of Positives Using SARS-CoV-2 Antigen Test Only
Number of staff who tested positive using SARS-CoV-2 antigen test only (no other testing performed).

Number of Positives Using SARS-CoV-2 NAAT (PCR) Test Only
Number of staff who tested positive using SARS-CoV-2 NAAT (PCR) test only (no other testing performed).

Number of Positives Using SARS-CoV-2 Test and Negative SARS CoV-2 NAAT (PCR) Test
Number of staff who tested positive using SARS-CoV-2 antigen test and negative SARS CoV-2 NAAT (PCR). Only include if the two tests performed within 2 days of each other.

Number of Positives Using any Combination of Tests
Number of staff who tested positive using any combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s). Only include if the two tests performed within 2 days of each other.

Number of Re-Infections among Staff Since (0 - 0) NHSN
Of the 0 reported staff above with a positive test result, how many were considered as re-infected?

Types of Staff Re-Infections

Number of Symptomatic Re-Infections among Residents/Clients
Of the 0 reported staff with re-infections, how many had signs and/or symptoms consistent with COVID-19?

Number of Asymptomatic Re-Infections among Residents/Clients Since
Of the 0 reported staff with re-infections, how many did not have signs and/or symptoms consistent with COVID-19?

Number of New Deaths among Staff from COVID-19 Since (0 - 1000) NHSN
New number of staff deaths due to COVID-19 since your last report.

Current Number of Influenza Cases among Staff Since (0 - 1000) NHSN
Number of staff with new influenza (flu) since your last report.

Current Number of Influenza with COVID-19 Cases among Staff Since (0 - ) NHSN
Number of staff with BOTH influenza (flu) AND COVID-19 since your last report.

Current Number of Respiratory Illnesses among Staff Since (0 - ) NHSN
Number of staff with acute respiratory illness symptoms, NOT COVID-19 and/or influenza (flu) since your last report.

Can the Facility Test Staff Within the Next 7 Days if Needed? NHSN
Does your facility have the ability to perform or to obtain resources for performing COVID-19 viral testing on all current staff/personnel within the next 7 days, if needed?

Nursing Staff Shortage NHSN
Is your facility currently experiencing a shortage of nursing staff (registered nurse, licensed practical nurse, vocational nurse)?

Clinical Staff Shortage NHSN
Is your facility currently experiencing a shortage of clinical staff (physician, physician assistant, advanced practice nurse)?

Aide Shortage NHSN
Is your facility currently experiencing a shortage of aides (certified nursing assistant, nurse aide, medication aide, and medication technician)?

Other Staff Shortage NHSN
Is your facility currently experiencing a shortage of other staff or facility personnel not included in the categories above?

Testing Capability

Test Kit Trained DSHS
Select Yes if any current staff have been trained on how to use a COVID-19 test kit

In-House Point-of-Care Test Machine Available DSHS
Does the facility have point-of-care test machines to perform COVID-19 testing in-house?

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

BinaxNOW COVID-19 Ag Card

Lumira Dx SARS CoV-2 Ag

BD Veritor System

Sofia SARS Antigen FIA

Other

In-House PCR Testing DSHS
Is your facility completing PCR testing for positive antigen test results?

COVID-19 Testing Performed Since NHSN
Select Yes if your facility performed any COVID-19 testing since your last report

Number of In-House Point-of-Care Tests on Residents Since NHSN
Number of in-house COVID-19 point-of-care tests performed on residents since your last report.

Number on NON Point-of-Care Tests on Residents/Clients NHSN
Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on residents

Number of In-House Point-of-Care Tests on Staff Since NHSN
Number of in-house COVID-19 point-of-care tests performed on staff since your last report.

Number on NON Point-of-Care Tests on Staff NHSN
Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on staff

Average Turnaround Time for Test Results NHSN
During the past two weeks, on average, how long did it take your facility to receive COVID-19 test results?

Supplies and Personal Protective Equipment

Facility Strategy for Optimizing N95 Respirator Supply (Required) NHSN

Urgent Need for N95 Masks? NHSN
Indicate if facility will no longer have N95 in 7 days

Facility Strategy for Optimizing Surgical Mask Supply NHSN

Urgent Need for Face Masks? NHSN
Indicate if facility will no longer have face masks in 7 days

Facility Strategy for Optimizing Eye Protection Supply NHSN
Including face shields and goggles

Urgent Need for Eye Protection? NHSN
Indicate if facility will no longer have eye protection in 7 days

Facility Strategy for Optimizing Gown Supply NHSN

Urgent Need for Gowns? NHSN
Indicate if facility will no longer have gowns in 7 days

Facility Strategy for Optimizing Glove Supply NHSN

Urgent Need for Gloves? NHSN
Indicate if facility will no longer have gloves in 7 days

Does the Facility have Alcohol Based Hand Rub (ABHR) Available for Use?

Urgent Need for Alcohol Based Hand Rub? NHSN
Indicate if facility will no longer have ABHR in 7 days

Ventilators

Ventilator Unit Available (Required) NHSN
Select Yes, if your facility has a ventilator-dependent unit

Number of Ventilators (0 - ) NHSN
Total number of ventilators available in your facility, including portable ventilators

Ventilators in Use (0 - ) NHSN
Total number of ventilators in use in your facility for suspected or confirmed COVID-19, including portable ventilators

Ventilator Supplies NHSN
Amount of supplies available for ventilators, including tubing

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.

Staff Shortages NHSN

Personal Protective Equipment Shortages NHSN

SARS-CoV-2 (COVID-19) Testing Supply Shortages NHSN

Infection Control/ Outbreak Management NHSN

Staff Training NHSN

COVID-19 Vaccine Access (Residents and/or Staff) NHSN

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