COVID-19 Facility Reporting

Every Tuesday by noon, please report all NEW cases of COVID 19 in residents AND staff for the week ending on that Tuesday. Please also report your TOTAL (cumulative) number of cases in residents AND staff.

1. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Facility Name: *This question is required.

3. Facility Name (Other): *This question is required.

3. Facility Phone Number (number only - no dashes): *This question is required. This question requires a valid number format.

4. Your Name: *This question is required.

5. Your Email: *This question is required. This question requires a valid email address.

6. Type of facility (select all that apply): *This question is required.

Nursing Home (Skilled Nursing Facility)
Residential Care Facility (Assisted Living Facility)
Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)

7. Nursing Home New Positive Residents: This question requires a valid number format.

7. Nursing Home Total Positive Residents: This question requires a valid number format.

7. Nursing Home New Positive Staff: This question requires a valid number format.

7. Nursing Home Total Positive Staff: This question requires a valid number format.

7. Residential Care Facility New Positive Residents: This question requires a valid number format.

7. Residential Care Facility Total Positive Residents: This question requires a valid number format.

7. Residential Care Facility New Positive Staff: This question requires a valid number format.

7. Residential Care Facility Total Positive Staff: This question requires a valid number format.

7. Intermediate Care Facility for Individuals with Intellectual Disabilities New Positive Residents: This question requires a valid number format.

7. Intermediate Care Facility for Individuals with Intellectual Disabilities Total Positive Residents: This question requires a valid number format.

7. Intermediate Care Facility for Individuals with Intellectual Disabilities New Positive Staff: This question requires a valid number format.

7. Intermediate Care Facility for Individuals with Intellectual Disabilities Total Positive Staff: This question requires a valid number format.