FAQs on Reporting COVID-19 Vaccination Data

November 2021

Data Reporting: General

Q1. Where can facilities access training materials on reporting COVID-19 vaccination data through NHSN?

NHSN has developed many resources for facilities. Facilities can visit the following webpage to access training materials on reporting COVID-19 vaccination data through NHSN:

These webpages contain data collection forms, tables of instructions for reporting data, training slides, reporting and analysis guides, data tracking worksheets and .CSV file templates and instructions.

 

Q2. Where can I find information on the Centers for Medicare and Medicaid Services (CMS) final rule for acute care and long-term acute care facilities on reporting healthcare personnel COVID-19 vaccination summary data?

Please refer to the following rule:

Federal Register :: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Changes to Medicaid Provider Enrollment; and Changes to the Medicare Shared Savings Programexternal icon

 

Q3. Where can I find information on the CMS final rule for inpatient psychiatric facilities (IPFs) on reporting healthcare personnel COVID-19 vaccination summary data?

Please refer to the following rule: Federal Register :: Medicare Program; FY 2022 Inpatient Psychiatric Facilities Prospective Payment System and Quality Reporting Updates for Fiscal Year Beginning October 1, 2021 (FY 2022)external icon

 

Q4. Where can I find information on the CMS final rule for inpatient rehabilitation facilities (IRFs) reporting healthcare personnel COVID-19 vaccination summary data?

Please refer to the following rule: Federal Register :: Medicare Program; Inpatient Rehabilitation Facility Prospective Payment System for Federal Fiscal Year 2022 and Updates to the IRF Quality Reporting Program; Payment for Complex Rehabilitative Wheelchairs and Related Accessories (Including Seating Systems) and Seat and Back Cushions Furnished in Connection With Such Wheelchairsexternal icon

 

Q5. Who can contact if I have questions on the CMS reporting requirements?

Please contact the programs listed below for specific facility types:

 

Q6. Are non-long-term care facilities required to report data through the COVID-19 Vaccination Module weekly or once a month?

NHSN allows for and encourages weekly submission of COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module.  Beginning on October 1, facility types that are part of the Inpatient Quality Reporting Program will need to submit COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module for at least one week per month to fulfill CMS reporting requirements. Facilities can select any week within the month to report data. Facilities may choose to report these data weekly. COVID-19 vaccination data should be submitted by the end of the quarter as defined by CMS. A week is designated as belonging to the month of the week-end date. For example, reporting data for the week of September 27 through October 3 is considered as submitting data for a week in October.

 

Q7. Should facilities complete all data fields of the COVID-19 Vaccination Modules?

CDC encourages facilities to complete all data fields of the COVID-19 Vaccination Modules. However, not all data fields are required. Only fields designated with a red asterisk (*) next to the question are required to save the data.

 

Q8. What is the monthly reporting plan in NHSN and how is it used for COVID-19 vaccination data reporting?

The monthly reporting plan indicates to the NHSN system which modules and protocols a user intends to follow for surveillance purposes in a specific month. The plan must be completed before data are entered for that month. Monthly reporting plans must be created or updated to include resident and healthcare personnel COVID-19 vaccination summary reporting, i.e., vaccination data must be “in-plan” for data to be shared with the Centers for Medicare and Medicaid Services (CMS).

Please note that if facilities would like to create a monthly reporting plan, they should be sure that the “no modules followed this month” option is not selected when attempting to create a monthly reporting plan in the NHSN application.

 

Q9. How should facilities report cumulative data?

Report the total number of individuals at the facility for that week. Then, of these individuals, report the number who have ever received COVID-19 vaccination (at that facility or elsewhere) since it became available in December 2020. Do not limit reporting to just the individuals who were vaccinated that week; instead, report the cumulative total of all individuals who have ever been vaccinated to date.

For example, 50 healthcare personnel received only dose 1 of the Moderna COVID-19 vaccine during the first week of reporting. During the second week, 5 more healthcare personnel received only dose 1 of the Moderna COVID-19 vaccine. Therefore, the facility should report that 55 individuals received only dose 1 of the Moderna COVID-19 vaccine by the end of the second week.

 

Q10. Which healthcare personnel should I include in the weekly COVID-19 vaccination data?

Facilities should report COVID-19 vaccination data on healthcare personnel who were eligible to have worked at this healthcare facility for at least 1 day during the week of data collection, regardless of clinical responsibility or patient contact. To save a data record in the NHSN application, facilities must enter data on four categories of healthcare personnel: employees, licensed independent practitioners (non-employee physicians, advanced practice nurses, and physician assistants), adult students/trainees and volunteers aged 18 and over, and other contract personnel. 

 

Q11. Which healthcare personnel are considered eligible to have worked at the healthcare facility?

Healthcare personnel eligible to have worked include those scheduled to work in the facility at least one day every week. Working any part of a day is considered as working one day. Facilities should include healthcare personnel even if they are on temporary leave during the week of data collection. Temporary leave is defined as less than or equal to two weeks in duration. If they are on leave that is greater than two weeks, then they should not be included for the week of data collection.

 

Q12. What types of nurses are considered licensed independent practitioners?

Advanced practice nurses include nurse practitioners, nurse midwives, clinical nurse specialists, and nurse anesthetists.  Advanced practice nurses paid through a contract should be reported in the licensed independent practitioner category. However, advanced practice nurses who are employees of the facility should be reported under employees (staff on payroll). Please note that travel nurses should be included under ‘other contract personnel’ if they are not considered advanced practice nurses and are paid through a contract.

 

Q13.  Should we include ambulance workers in the data?

Ambulance workers who physically perform work duties inside the facility (such as patient transporters) and who are eligible to have worked at the facility for at least 1 day during the week of data collection would be included (under the other contract personnel category if they are paid through a contract or vendor, or under the employee category if they are directly employed by the facility). However, ambulance drivers who do not physically work inside the facility would not be included.

 

Q14. Vendors or sales representatives come into my facility or unit and may be present during surgeries or other patient care activities. Should we count these vendors in the other contract personnel category?

Yes, vendors providing care, treatment, or services should be included in the other contract personnel category if they work in the facility on a regular (weekly) basis, regardless of clinical responsibility or patient contact.

 

Q15. What are examples of contracted and vendor HCP who should be included in NHSN COVID-19 Vaccination reporting.

The list below includes examples of contracted and vendor HCP who provide direct patient care and who perform non-direct or non-patient care duties. This list is not exhaustive.

Contracted and vendor HCP can include the following non-employee care providers who may or may not be involved in patient care:

  • Admitting staff/clerical support/registrars
  • Agency nurses
  • Ambulance drivers (who enter the facility to assist with transportation)
  • Biomedical engineers
  • Central supply staff
  • Chaplains
  • Construction workers (working inside the facility)
  • Dietary/food service staff
  • Dieticians
  • Dialysis technicians
  • EKG technicians
  • EMG technicians
  • Home health aides
  • Housekeeping staff
  • Information Technology staff
  • Laboratory: Phlebotomists
  • Laboratory: Technicians
  • Landscapers (working inside the facility)
  • Laundry staff
  • Maintenance staff/engineers
  • Nursing aides
  • Occupational therapists
  • Patient care technicians
  • Patient transporters
  • Pharmacists
  • Pharmacy/medication technicians
  • Physical therapists
  • Psychologists
  • Psychology technicians/Mental health workers
  • Radiology: X-ray technicians
  • Recreational therapists/Music therapists
  • Respiratory therapists
  • Security staff
  • Social workers/Case managers
  • Speech therapists
  • Surgical technicians
  • Traveling nurses
  • Ultrasound technicians
  • Utilization review nurses

 

Q16. Should I count healthcare personnel who are not working with patients, but because of staff meetings, etc. are physically in the facility?

You should count healthcare personnel who are eligible to work at the facility, regardless of clinical responsibility or patient contact.  For example, you should count healthcare personnel having official responsibilities in the facility such as attending regularly scheduled meetings or required training. However, you would not need to count healthcare personnel who are not officially in the facility for work duties (e.g., coming into the facility for lunch) during the reporting period.

 

Q17. Should employees who always work off-site, remotely, or out-of-state, such as employees practicing telemedicine, be included in our data reports?

No. Only healthcare personnel who are eligible to physically work at the healthcare facility are included.

 

Q18. Should I include healthcare personnel who are on sick leave in the weekly COVID-19 vaccination data?

Facilities should include healthcare personnel if they are on temporary leave during the week of data collection. Temporary leave is defined as less than or equal to 2 weeks in duration. Examples of temporary leave may include sick leave or vacation. In instances where temporary leave extends past 2 weeks, the healthcare worker should not be included in question #1 for the current week of data collection. Therefore, facilities would include an individual who was on sick leave for 3 days during the week. However, an individual on maternity leave for 2 months would not be included in the data.

 

Q19. Should I include individuals not yet eligible to receive COVID-19 vaccination due to age in the data?

Individuals not yet eligible to receive COVID-19 vaccination because of their age, such as children, should be excluded from question #1 on the data collection form.

 

Q20. If an individual works at multiple facilities, does each facility need to report vaccination data for this individual through NHSN?

Yes. These reports describe vaccination rates among individuals working at a specific facility, so all eligible individuals must be counted at each facility where they work during the week of data collection.

 

Q21. Our facility started administering COVID-19 vaccines in January 2021. Should my facility enter data in NHSN beginning with the first week vaccines were administered in January 2021?

Facilities can enter (and edit) data retrospectively; however, they are not required to do so. Remember that when reporting for any calendar week, report the total number of individuals at the facility for that week. Then, of these individuals, report the number who have ever received COVID-19 vaccination (at that facility or elsewhere) since it became available in December 2020.

 

Q22. What if there are no changes to my data from one week to the next?

If there are no changes to your data (for example, there are not any changes in the number of individuals and their vaccination status), then you would report the same numbers as the previously reported week. Because there could be new staff, residents, and/or patients joining or leaving the facility, vaccination coverage could change week by week even though no new vaccines are given.

 

Q23. I entered and saved data into the NHSN application for the incorrect week. What should I do?

Once COVID-19 vaccination data are entered and saved in NHSN, a week cannot be deleted in its entirety. We recommend that you enter the appropriate data for the week data were entered incorrectly. If you do not have these data available, enter zeros (0) on the data collection form for the incorrect week. Please note that data can be updated or edited at any time. For the correct week, you can proceed to enter your COVID-19 vaccination data.

 

Q24. How should we report healthcare personnel who no longer work at the facility?

Please include healthcare personnel who were eligible to have worked at this healthcare facility for at least 1 day during the week of data collection, regardless of clinical responsibility or patient contact. For example, if an individual worked at the facility from Monday through Thursday but was terminated on Friday of the current reporting week, you would still include the individual in the data for the current reporting week. However, you would remove the individual from your data for subsequent reporting weeks.

 

Q25. Is the Janssen COVID-19 vaccine the same as the Johnson & Johnson COVID-19 vaccine?

Yes. These are the same vaccines.

 

Q26. Individuals at my facility received COVID-19 vaccine from various manufacturers. How should I report these data through NHSN?

Facilities should report COVID-19 vaccination data for all vaccine manufacturers as applicable. To enter data for more than one vaccine manufacturer in Question #2, please follow the following steps:

Step 1: Select a COVID-19 vaccine from the drop-down box.
Step 2: Enter the cumulative number of individuals who received only dose 1 of vaccine.
Step 3: Enter the cumulative number of individuals who received both dose 1 and dose 2 of vaccine.
Step 4: If some individuals received another type of vaccine, then return to the drop-down box and select the other vaccine and repeat steps 1 through 3 as described above.

 

Q27. How should facilities report data for individuals receiving only dose 1 and those receiving dose 1 and dose 2 of an initial two-dose COVID-19 vaccine series?

For question 2 of the COVID-19 Vaccination Modules, facilities report the number of individuals who have received only dose 1 of a two-dose COVID-19 vaccine and separately report the number of individuals who have received dose 1 and dose 2 of a two-dose COVID-19 vaccine.

For example, 10 individuals received dose 1 of the Moderna COVID-19 vaccine. One month later, 3 of the 10 individuals received dose 2 of the Moderna COVID-19 vaccine. The 3 individuals who received dose 2 of the Moderna COVID-19 vaccine would then be reported as receiving dose 1 and dose 2 of the Moderna vaccine. The other 7 individuals would still be reported as receiving only dose 1 of the Moderna COVID-19 vaccine.

 

Q28. How should we categorize individuals who do not want to disclose their vaccination status?

Please report these individuals in question 3.3 under “Unknown COVID-19 Vaccination Status.”

 

Q29. An individual received the first dose of an initial COVID-19 vaccine but declined to receive the second dose. How should we categorize this individual?

The individual should be counted only as receiving the first vaccine dose. They would not be counted as declining the vaccine. Individuals should only be counted in question 3.2 as declining vaccination if they declined to receive any doses of the vaccine.

 

Q30. An individual received the first dose of an initial COVID-19 vaccine but had a severe allergic reaction to this. As a result, the individual did not receive the second vaccine dose. How should we categorize this individual?

The individual should be categorized in question 3.1 as having a medical contraindication to COVID-19 vaccine due to their severe allergic reaction after a previous dose of COVID-19 vaccine.

 

Q31. If an individual received two doses of an initial COVID-19 vaccine series, but the manufacturer for one dose is unknown, how should this be categorized?

If the manufacturer for one or more doses of vaccine is unknown, you would record the vaccination status for the individual in the “Unspecified Manufacturer” category.

 

Q32. If an individual received two doses of an initial COVID-19 vaccine series, each from different manufacturers, how should this be categorized?

Individuals who received a complete two-dose COVID-19 vaccination series and had documentation of different manufacturers for both doses should be counted in the “Unspecified Manufacturer” category.

 

Q33. An individual received an initial COVID-19 vaccine series that is not Food and Drug Administration (FDA) approved or authorized. How should we categorize this individual?

Individuals who received all recommended doses of an initialCOVID-19 vaccine series that is neither approved nor authorized by FDA but listed for emergency use by the World Health Organization (WHO) should be counted in the “Unspecified Manufacturer” category (question 2.99), if they provide documentation of vaccination. Please refer to Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC for the complete list of COVID-19 vaccines that have received an emergency use listing from WHO.

 

Q34. What is considered acceptable documentation for an individual vaccinated outside of the healthcare facility?

Acceptable forms of documentation include a signed statement or form, or an electronic form or e-mail from the individual indicating when and where they received the COVID-19 vaccine.  A note, receipt, vaccination card, etc. from the outside vaccinating entity stating that the individual received the COVID-19 vaccine at that location is also permitted. Verbal statements are not acceptable to document vaccination outside the facility for the purposes of NHSN COVID-19 vaccination summary data reporting.

 

Q35. If an individual cannot produce any documentation of initial COVID-19 vaccination series received outside of the facility, how should this be categorized?

If individuals cannot provide any documentation of vaccination, they should be reported in question 3.3 under “Unknown COVID-19 Vaccination Status.”

 

Q36. What are considered medical contraindications for COVID-19 vaccination?

The latest information on medical contraindications may be found in Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States. For NHSN COVID-19 vaccination surveillance, philosophical, religious, or other reasons for declining COVID-19 vaccine not listed in the Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States are not considered medical contraindications for COVID-19 vaccination.

 

Q37. Question 3.1 on medical contraindications is required for saving data in NHSN. How should I complete this question if I was unable to obtain information on medical contraindications for individuals at my facility?

If a facility is not able to obtain information on medical contraindications, then the facility can enter a zero (0) in the NHSN application for this question.

 

Q38. Which individuals are considered completely vaccinated?

Completely vaccinated individuals have completed an initial COVID-19 vaccine series.

 

Q39. How do I categorize an individual who was granted a religious or personal belief exemption to COVID-19 vaccination according to their facility’s policy?

An individual who declines to receive vaccination for any reason other than the medical contraindications listed in Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States   should be categorized as declined to receive COVID-19 vaccination for question 3.2. This is true even if your facility permits religious or philosophical exemptions for COVID-19 vaccination.

 

Q40. How are additional and booster doses defined?

An additional dose refers to an additional dose of vaccine administered when the immune response following an initial completed vaccine series is likely to be insufficient. A booster dose refers to an additional dose of vaccine administered when the initial sufficient immune response to an initial completed vaccine series is likely to have waned over time.

 

Q41. What is the difference between an initial COVID-19 vaccination series and an additional dose or booster?

The initial completed COVID-19 vaccine series received by an individual since December 2020 includes dose 1 and dose 2 of COVID-19 vaccines requiring two doses for completion or one dose of COVID-19 vaccine requiring only one dose for completion. The additional dose or booster is received at least two weeks or more after completing an initial vaccine series.

 

Q42. Can facilities enter data on additional doses or boosters for COVID-19 vaccine?

Yes, facilities enter data on additional doses or boosters for COVID-19 vaccine in question 4 and question 5 of the data entry form. Question 4 requires facilities to report on the cumulative number of individuals eligible to receive an additional dose or booster of COVID-19 vaccine. Question 5 requires facilities to report on the cumulative number of individuals who received an additional dose or booster of COVID-19 vaccine (by manufacturer type).

 

Q43. How should my facility determine who is considered eligible for an additional dose or booster dose at this time?

Facilities should refer to the CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States to determine individuals who are eligible to receive additional doses or boosters after receiving an initial completed vaccination series. As of November 2021, individuals eligible to receive an additional or booster dose include the following:

Individuals eligible to receive an additional or booster dose as of October 2021
Category Primary Vaccine Series Time Since Primary
Vaccine Series Completion
Eligible for
Moderately and severely immunocompromised people mRNA ≥2 weeks Additional dose
Persons aged ≥12 years who received a Janssen primary series Janssen ≥2 months Booster dose
Persons aged ≥12 years mRNA ≥5 months Booster dose

 

Q44. My facility has a staff member who only received dose 1 of the Moderna initial COVID-19 vaccine series. However, this staff member expressed an interest in receiving an additional or booster dose of the vaccine. How should I categorize this staff member?

The facility would not include the staff member in questions 4 and 5 on the data collection form since he/she did not complete an initial COVID-19 vaccination series. This staff member would only be eligible for an additional or booster dose 6 months after completing their initial COVID-19 vaccine series.

 

Q45. My facility cannot determine if an individual is eligible for an additional dose at this time because we do not know of the individual’s health status to determine if he/she is moderately to severely immunocompromised.

If a facility is unable to determine whether an individual is considered eligible to receive an additional dose at this time, the individual should not be reported in question 4 or question 5 as eligible to receive an additional dose on the data collection form. Keep in mind that while you may not be able to determine eligibility for an additional dose, the individual could still be eligible for a booster dose. Refer to CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States for eligibility criteria.

 

Q46. Question 6 on the data collection form pertains to COVID-19 vaccine supply at a facility. Question 6.1 asks about if a facility is enrolled as COVID-19 vaccination provider. What is the definition of a COVID-19 vaccine provider?

At this time, all COVID-19 vaccine in the United States has been purchased by the U.S. government for administration exclusively by providers enrolled in the CDC COVID-19 Vaccination Program. Only healthcare professionals enrolled as vaccination providers directly through a health practice or organization can legally store, handle, and administer COVID-19 vaccine in the United States. Check here for additional details. How to Enroll as a COVID-19 Vaccination Provider | CDC.

 

Q47. How should acute care facilities report healthcare personnel COVID-19 vaccination summary data?

Facilities should follow the guidance below when making determinations about which areas of the acute care facility to include when reporting healthcare personnel COVID-19 vaccination summary data to NHSN as part of the CMS Hospital Inpatient Quality Reporting (IQR) Program:

  • Include all inpatient units/departments of the acute care facility sharing the exact same CMS Certification Number [CCN] (100% identical) as the acute care facility, regardless of distance from the facility.
  • Include all outpatient units/departments of the acute care facility sharing the exact same CCN (100% identical) as the acute care facility, regardless of distance from the facility.
  • Exclude all inpatient and outpatient units/departments of the acute care facility with a different CCN (even if different by only one letter or number) from the acute care facility.

 

Q48. Why are free-standing inpatient psychiatric facilities (IPFs) required to enroll in NHSN, while IPF units having different CMS certification numbers (CCNs) from the acute care or critical access facilities usually do not need to do so?

IPF units do not need to enroll or activate the Healthcare Personnel Safety (HPS) Component unless their affiliated acute care or critical access facility is not already enrolled in NHSN or the IPF unit is not physically located within the walls of the affiliated acute care or critical access facility. IPF units located within hospitals can simply be mapped as locations of the already-enrolled acute care or critical access facility. Once the IPF unit is added as a location of the facility, the IPF unit-specific CCN is linked with that location. View more information about how to map an IPF unit and add an IPF unit-specific CCN pdf icon[PDF – 200 KB].

 

Q49. I am reporting data for an inpatient rehabilitation facility (IRF) unit that is physically located within our acute care facility. The IRF unit has the same CCN as the hospital except for an “R” or “T” in the third position. How should I report the IRF unit data in NHSN?

COVID-19 vaccination summary data for healthcare personnel working in this IRF unit should be reported separately from the acute care hospital summary data because the unit has a different CCN. You would need to add a separate monthly reporting plan for the IRF unit. Next, on data entry screen, use the dropdown box under the location field to enter separate data for your IRF unit. Healthcare personnel eligible to work in the IRF unit should not be counted in the summary report for the rest of the acute care facility unless they are also eligible to work in other inpatient or outpatient units of the acute care facility. Please refer to the training slide sets for the NHSN COVID-19 Vaccination Modules for more information.

 

Q50. I need to report healthcare personnel COVID-19 vaccination summary data for an IPF and/or IRF unit. How do I add these units as locations to my existing facility in NHSN?

View more information about how to map an IPF unit and add an IPF unit-specific CCN pdf iconpdf icon[PDF – 200 KB].

View more information about how to add an IRF unit as a location in your facility pdf icon[PDF – 500 KB].

 

Q51. There are multiple IRF units located within my facility. Should I report healthcare personnel COVID-19 vaccination summary data separately in NHSN for each individual unit?

No.  The healthcare personnel COVID-19 vaccination summary data of each individual IRF unit should be combined and submitted to NHSN as a single summary data report combining all CMS IRF units within the facility.

 

Q52. Can I submit COVID-19 vaccination data for an IPF and/or IRF unit in the same .CSV file as the COVID-19 vaccination data for its affiliated acute care or critical access facility?

No.  A .CSV file can only contain one OrgID per reporting week. Facilities or groups that wish to report COVID-19 vaccination data for an IPF and/or IRF unit via .CSV file should submit IPF and/or IRF unit data in a separate .CSV file from the acute care or critical access facility data.

 

Q53. If my IRF unit or IPF unit has the exact same CCN as my acute care or critical access facility, do I need to report the IRF or IPF unit data separately from this facility?

No.  If the IRF or IPF unit CCN is 100% identical to the CCN of its acute care or critical access facility, then separate healthcare personnel COVID-19 vaccination summary data reporting is not required by CMS.  Therefore, counts of healthcare personnel working in the IRF or IPF unit can be included in the total counts for the acute care or critical access facility. However, IRF or IPF units whose CCNs differ from the acute care or critical access facility CCN by even one letter or number – for example, having a “T” or “R” in the third position – must either be mapped as locations of the parent facility or enrolled as a separate NHSN facility, and their data must be reported separately.

 

Q54. Are there tools to help account for staff or resident turnover at my facility?

CDC has developed data tracking worksheets that will automatically calculate data for entry each week for the COVID-19 Vaccination Modules. For example, the worksheet for residents of long-term care facilities can be used to track the number of residents who receive COVID-19 vaccination. After entering COVID-19 vaccination data for each resident in the worksheet, simply select a reporting week, and the worksheet will automatically calculate each entry that should be reported to NHSN for that week.

The data tracking worksheets can be found under the “Supporting Materials” section of the following webpages:

 

Q55. The NHSN COVID-19 vaccination data tracking worksheets are password-protected. Can CDC provide a version of the worksheet that is not password-protected?

The cells in the worksheet are locked to prevent the many formulas in the worksheet from becoming compromised. This will ensure that the data entered into the worksheet data are summarized and calculated correctly. If you would like to track additional information (such as adding columns to the worksheet), CDC recommends that facilities create their own worksheet by copying the information from the CDC-developed worksheet into a new worksheet. Please note that the any new worksheets created will be outside the scope of the CDC-developed worksheets. View more information on how to use the data tracking worksheets pdf icon[PDF – 600 KB].

 

Q56. How can facilities submit COVID-19 vaccination data through NHSN?

Facilities have two options for data submission. One option is that facilities can enter data directly into the NHSN application. Another option is to submit COVID-19 vaccination data to NHSN is using .CSV file upload. The .CSV file templates and instructions for uploading COVID-19 vaccination data can be found under the “Supporting Materials” section of the following webpages:

 

Q57. What is the maximum file size for uploading .CSV files of COVID-19 vaccination data?

We recommend uploading files with a maximum of 500 rows to enable successful file upload for facilities submitting COVID-19 vaccination data through large .CSV files

 

Q58. Are there any alerts built into the .CSV files to prevent mathematical errors?

The .CSV upload has an alert built into the reporting grid to show a message that indicates when the upload is successful. NHSN will automatically populate the uploaded data. If errors are found during upload, a window displaying a description of these errors will be generated.

 

Q59. Why should facilities report data through NHSN if vaccination data are already submitted through other systems, such as the Immunization Information Systems (IIS)?

Facilities are encouraged to report data through NHSN (in addition to any other data reporting systems), because NHSN collects COVID-19 vaccination data for your facility. Most state Immunization Information Systems do not include the information needed to determine if an immunized person is a resident of a nursing home, a dialysis patient, or a healthcare worker. Using the NHSN COVID-19 Vaccination Modules allows tracking vaccination coverage among the residents, patients, or healthcare personnel in your facilities.

 

Q60. Who should facilities contact for questions about reporting COVID-19 vaccination data through NHSN?

Please send an e-mail to: nhsn@cdc.gov and include ‘Weekly COVID-19 Vaccination’ in the subject line of the e-mail.

Reporting: Dialysis Facilities

Q1. Are facilities required to report healthcare personnel and patient COVID-19 vaccination data through NHSN?

The Centers for Medicare and Medicaid Services’ (CMS) End Stage Renal Disease (ESRD) Network program established COVID-19 vaccination reporting requirements beginning March 2021. Since data reporting requirements are established by the ESRD Network program, we recommend that you contact your ESRD Network. Your ESRD Network will be able to provide you with the relevant information on reporting COVID-19 vaccination data through NHSN for healthcare personnel and patients of dialysis facilities.

 

Q2. What is the reporting week for submitting COVID-19 vaccination data for dialysis patients?

Each calendar week begins on a Wednesday and ends on a Tuesday.

 

Q3. Which patients do I include in question #1 on the data collection form?

You would include all patients receiving dialysis care from the facility during the week of reporting, whether they received care at the facility or at home. Home dialysis patients include those receiving hemodialysis and peritoneal dialysis at home.

 

Q4. How do you count a patient who receives care from the facility each week?

If a patient receives care from the dialysis facility for multiple weeks, you should count the patient for each week the patient receives care. For example, if a patient received care from the dialysis facility for five weeks, you would include the patient in the facility’s data for each of the five weeks.

 

Q5. When reporting the number of patients receiving dialysis care from the facility during the current reporting week, do we include patients that expired?

Yes, if the patient received care in the facility for at least 1 day during the reporting week, they would be counted in Question #1 on the data collection form for the current week. However, these patients would not be included in data reporting for subsequent weeks.

 

Q6. Should I report data for a patient who received dialysis treatment during a recent hospitalization by another facility?

Please include patients treated by your outpatient dialysis facility at least 1 day during the reporting week. If a patient only received dialysis care during a hospitalization you should not report data for that patient. However, if a patient was hospitalized during the week and was also treated by your dialysis facility at least 1 day during the reporting week, then you should report data for that patient.

 

Q7. How should I report data for patients with chronic or acute conditions?

Please include all patients who received dialysis care from the facility during the week, including those with chronic or acute conditions.

 

Q8. For hospital-based programs, do healthcare personnel need to be reported in both the hospital and dialysis facility data?

If healthcare personnel were eligible to have worked in hospital and dialysis facility, each facility should include the personnel in their data.

 

Q9. How should we report data if none of the patients at my facility have received an initial COVID-19 vaccine series?

If no patients have received an initial COVID-19 vaccine series at the facility or elsewhere, please enter a zero (0) for Question #2 on the data collection form. Facilities still must complete Question #1 and enter the total number of patients receiving dialysis care from the facility and provide answers to all other required fields (indicated by an asterisk) to save data.

 

Q10. My outpatient dialysis unit does not provide vaccination, but it is located within a hospital that does provide COVID-19 vaccination. How should I answer question 6.1 “Is your facility enrolled as a COVID-19 vaccination provider?”

If the outpatient dialysis unit does not provide vaccination, but it is located within a hospital that does provide COVID-19 vaccination, you would select “No” for question 6.1.

 

Q11. Should we report adverse events if the vaccine was not given at the outpatient dialysis facility?

Facilities should report clinically significant COVID-19 vaccine adverse events to any doses of the specific COVID-19 vaccine, given at the dialysis facility or outside the facility. Adverse events should be reported to the Vaccine Adverse Event Reporting System: https://vaers.hhs.gov/external icon.

 

Q12. Do individual outpatient dialysis facilities need to confer rights for networks to view the weekly COVID-19 vaccination data for dialysis patients?

NHSN has set up auto-confer rights on weekly COVID-19 vaccination summary reporting for outpatient dialysis facilities.

Q13. Can multiple groups upload .CSV files of COVID-19 vaccination data?

NHSN users can belong to multiple groups. Users should be sure they are uploading and/or viewing COVID-19 vaccination data for the correct group in NHSN. Users should be logged into the Healthcare Personnel Safety Component for uploading and/or viewing COVID-19 vaccination data for healthcare personnel. The Dialysis Component should be used for uploading and/or viewing COVID-19 vaccination data for patients.

Data Reporting: Long-term Care Facilities

Q1. What level of Secure Access Management Service (SAMS) access do long-term care facilities need to report COVID-19 vaccination data through NHSN?

Long-term care facilities can currently access the NHSN COVID-19 Vaccination Modules with Level 1 SAMS access. However, Level 1 access is an interim measure with limited access to the NHSN application. NHSN continues to encourage facilities to obtain Level 3 access once Level 1 registration is completed. The difference between Level 3 and Level 1 is data security safeguards, as Level 3 provides a more secure data upload.  If your facility does not have a Level 3 user, please contact the SAMS Help Desk between the hours of 8:00 AM and 8:00 PM EST Monday through Friday (excepting U.S. Federal holidays) at the following: Toll Free: 877-681-2901; E-mail: samshelp@cdc.gov. You can also find additional information in the SAMS User FAQs published on the SAMS Homepage at https://sams.cdc.gov.

 

Q2. How should I report weekly COVID-19 vaccination data through NHSN?

COVID-19 vaccination data for healthcare personnel and residents is to be reported to NHSN each calendar week and must represent data for each standard week, which is Monday through Sunday. For example, vaccination data for the week of Monday, 5/10/2021 through Sunday, 5/16/2021 can be reported to NHSN during the following week (5/17/2021-5/23/2021). As another example, a nursing home reports COVID-19 vaccination data to NHSN every Wednesday. Data reported on Wednesday, May 26 represented vaccination data for the previous standard week of Monday, May 17 through Sunday, May 23. Data may also be reported during the current standard week if preferred. Data may be updated at any time.

Additional specific questions related to CMS reporting requirements for long-term care facilities and data submission deadlines should be sent to the following e-mail box: DNH_TriageTeam@cms.hhs.gov.

 

Q3. Are long-term care facility COVID-19 vaccination data reporting requirements only for skilled nursing facilities? Or are other types of facilities, such as assisted living and continuing care retirement communities, required to report COVID-19 vaccination data for residents and healthcare personnel?

At this time, only skilled nursing facilities are required to report COVID-19 vaccination data. Please see the CMS interim final rule: Federal Register: Medicare and Medicaid Programs; COVID-19 Vaccine Requirements for Long-Term Care (LTC) Facilities and Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICFs-IID) Residents, Clients, and Staffexternal iconexternal icon

Please see the CMS quality reporting program final rule: Federal Register :: Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2022 Rates; Quality Programs and Medicare Promoting Interoperability Program Requirements for Eligible Hospitals and Critical Access Hospitals; Changes to Medicaid Provider Enrollment; and Changes to the Medicare Shared Savings Programexternal icon

 

Q4. Which residents and healthcare personnel are eligible for an additional dose or booster dose at this time?

All residents and healthcare personnel are eligible for an additional dose or booster dose 6 months after receiving an initial completed COVID-19 vaccination series. For more information, facilities should refer to the CDC’s Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Approved or Authorized in the United States.

 

Q5. How should we report residents who have been discharged from the facility?

Please include residents occupying a bed at the facility for at least 1 day (at least 24 hours) during the week of data collection. For example, if a resident stayed at a facility for two days during the current reporting week but was then discharged, you would still include the resident in the data for the current reporting week. However, you would remove the resident from your data for subsequent reporting weeks.

 

Q6. Are we required to report weekly influenza vaccination data?

No. Weekly influenza vaccination data reporting for residents and healthcare personnel is not required at this time. The 2020-2021 influenza season has now passed; therefore, CDC is no longer reviewing weekly influenza vaccination data for this season. However, facilities have the option to use analysis and reporting options to view data entered for the 2020-2021 influenza season. In addition, CDC will not be collecting weekly influenza vaccination data for the 2021-2022 influenza season, and facilities will no longer be able to access the data entry screens for these data.

Please note that facilities can still enter annual healthcare personnel influenza vaccination summary data into NHSN using the Healthcare Personnel Safety Component. Training materials can be found using this link: HCP Flu Vaccination | HPS | NHSN | CDC.

 

Q7. If a pharmacy conducted COVID-19 vaccination clinics at my facility, do they report the vaccination data to NHSN or does my facility report the data?

Pharmacies and other vaccinating organizations are not reporting COVID-19 vaccination data to NHSN, so it is important for long-term care facilities to report these data to NHSN.