COVID-19 Facility Reporting

Please report the total number of residents and the total number of staff who were on isolation for confirmed or probable COVID-19 in your facility at any point during that week.

Numbers should be included for the following time period: Wednesday of the prior week through Tuesday of the current week.

1. Wednesday of prior week: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Tuesday of current week: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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3. Facility Name: *This question is required.

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

5. Type of facility: *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)

6. Nursing Home Resident Case Count: This question requires a valid number format.

6. Nursing Home Staff Case Count: This question requires a valid number format.

6. Residential Care Facility Resident Case Count: This question requires a valid number format.

6. Residential Care Facility Staff Case Count: This question requires a valid number format.

6. Intermediate Care Facility for Individuals with Intellectual Disabilities Resident Case Count: This question requires a valid number format.

6. Intermediate Care Facility for Individuals with Intellectual Disabilities Staff Case Count: This question requires a valid number format.