FAQs on Reporting COVID-19 Vaccination Data

Updated June 21, 2022

Data Reporting: Requirements

At this time, only skilled nursing facilities are required to report COVID-19 vaccination data.

Please refer to the final rule issued by the Centers for Medicare & Medicaid Service on 8/13/21.

CMS Skilled Nursing Facilities (SNFs) should also review the final rule issued by the Centers for Medicare & Medicaid Services on 5/13/21.

At this time, only skilled nursing facilities are required to report COVID-19 vaccination data.

Please refer to the final rule issued by the Centers for Medicare & Medicaid Services on 8/13/21

CMS Skilled Nursing Facilities (SNFs) should also review the final rule.

Please contact the programs listed below for specific facility types:

NHSN allows for, and encourages, weekly submission of COVID-19 vaccination data via the Weekly COVID-19 Vaccination Module.

Beginning on October 1, 2021, facility types that are part of the CMS Inpatient Quality Reporting Program (or Inpatient Psychiatric Facility Quality Reporting Program, Inpatient Rehabilitation Facility Quality Reporting Program, or Long-term Acute Care 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.

Beginning on January 1, 2022, ambulatory surgery centers are required 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.

Data Reporting: General

Yes, every data field is either required or conditionally required.

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

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 at the facility that week, report the number who have ever received COVID-19 vaccines (at that facility or elsewhere) since they became available in December 2020.

See the FAQs in the section titled Data Reporting: Requirements for information on the timeline for reporting requirements for quality reporting programs.

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.

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 where 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.

Facilities will no longer need to select a vaccine manufacturer when reporting Weekly COVID-19 Vaccination Module data beginning with reporting week-ending May 29, 2022.

If reporting data for a week prior to week-ending May 29, 2022:

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.

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.

Data Reporting: Primary Series

Among the individuals in question 1, 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 vaccinated that week; instead, report the cumulative total of all individuals in question 1 vaccinated to date.

The example below explains how to report the cumulative number of individuals receiving a partial primary vaccine series dose.

50 healthcare personnel received only dose 1 of a primary COVID-19 vaccine during the first week of reporting.

Week 1

screenshot of adding vaccine data
screenshot showing how to enter data for question 3.3

During the second week, 5 more healthcare personnel received only dose 1 of a primary COVID-19 vaccine.

Therefore, the facility should report that 55 individuals received only dose 1 of a primary COVID-19 vaccine by the end of the second week.

Week 2

A computer screenshot showing how to report data.

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 primary COVID-19 vaccine in question 2.1 and separately report the number of individuals who have received dose 1 and dose 2 of a two-dose primary COVID-19 vaccine in question 2.2.

Note that those who received 1 dose of a one-dose primary COVID-19 vaccine series are also captured in question 2.2.

For example, 10 individuals received dose 1 of a primary COVID-19 vaccine COVID-19 vaccine.

Month 1

A screenshot showing how to report COVID-19 data.

One month later, 3 of the 10 individuals received dose 2 of a two-dose primary series COVID-19 vaccine.

Month 2

A computer screenshot showing how to report covid-19 data.

The 3 individuals who received dose 2 of a two-dose primary series COVID-19 vaccine would then be reported as receiving dose 1 and dose 2 of a two-dose primary series vaccine.

The other 7 individuals would still be reported as receiving only dose 1 of a primary series COVID-19 vaccine.

Users would report these individuals as being included in question 2.2 “Any completed Primary COVID-19 vaccine series.”

Note that individuals who have received dose 1 and dose 2 of a two-dose primary COVID-19 vaccine are also counted in question 2.2.

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 as a medical contraindication 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 and should be reported under question 3.2, offered but declined COVID-19 vaccine.

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.

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.

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.

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.

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

If an individual has not received any doses of COVID-19 vaccine, but would like to be vaccinated, they should be reported in question 3.3 under “Unknown COVID-19 Vaccination Status.”

For example, if an individual stated that he/she has not had an opportunity to receive the vaccine but wishes to do so, they would be counted as “unknown”.

In addition, if an individual cannot produce documentation of COVID-19 vaccines received outside of the healthcare facility, they would be counted as “unknown.”

Alternatively, if an individual states he/she has not received any COVID-19 vaccines and does not intend to do so, they are reported in question 3.2 under “Offered but declined COVID-19 vaccine.”

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

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

These individuals are classified as unknown because it is unknown whether this single dose represents partial or complete primary series vaccination.

If an individual has received two doses of unknown or unspecified primary series vaccine, they should be reported under question 2.2, complete primary series of COVID-19 vaccination.

Data Reporting: Additional and Booster Doses

The primary 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 a primary vaccine series.

An additional dose is a subsequent dose of vaccine administered to people who are less likely to mount a protective immune response after initial vaccination.

People who are moderately or severely immunocompromised and who received Janssen COVID-19 Vaccine for their primary series should receive an additional dose.

A booster dose is a subsequent dose of vaccine administered to enhance or restore protection which might have waned over time after primary series vaccination.

Yes, facilities enter data on additional doses or boosters for COVID-19 vaccine for question 4 of the COVID-19 Vaccination Modules.

For question 4, facilities report the cumulative number of individuals with complete primary series vaccine in question 2.2 who have received any booster(s) or additional dose(s) of COVID-19 vaccine since August 2021.

For information on how to enter data for booster and additional doses for COVID-19 Vaccination Modules, please see the Table of Instructions for the HCP, LTC and Dialysis modules.

Facilities should refer to 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 a complete primary vaccination series.

Individuals are only counted for the doses they receive. The facility would count this staff member under question 2.1 (Only 1 dose of a two-dose Primary COVID-19 vaccine series).

The facility would not include the staff member in questions on additional or booster doses at this time.

This individual also would not be counted under question 5 since they are not considered up to date.

NHSN’s surveillance definition of up to date for COVID-19 vaccination data is based on CDC’s clinical considerations and up to date definition for the first day of the reporting quarter.

Please refer to COVID-19 Vaccination Modules: Understanding Key Terms [PDF – 212KB] for definitions of key terms related to COVID-19 vaccination for the purpose of NHSN public health surveillance.

NHSN surveillance definitions are designed to assess trends in the population and inform public health response.

NHSN must be able to standardize criteria and apply these definitions in a consistent manner across populations and time.

For the purpose of surveillance tracking, an NHSN surveillance definition must remain stable for a reporting quarter and will not be updated until the following quarter if CDC’s clinical considerations and up to date definition change.

Up to date vaccination

Individuals are considered up to date with their COVID-19 vaccines during the surveillance period of October 3, 2021 through June 26, 2022 for the purpose of NHSN surveillance if they meet one (1) of the following criteria*:

  1. An individual received all recommended doses in their primary vaccine series and received at least one booster dose.
    • An individual does not need to receive a second booster dose to be considered up to date at this time.
  2. An individual recently received all recommended doses in the primary vaccine series and is not yet eligible for a booster dose.
    • Individuals who are not yet eligible to receive a booster dose include:
      • Those who received their second dose of a 2-dose primary series of an mRNA COVID-19 vaccine (Pfizer-BioNTech or Moderna) less than 5 months ago.
      • Those who received a single dose of Janssen less than two months ago.

*Individuals with a moderately to severely immunocompromising condition are considered up to date in the following cases:

    • An individual received an additional dose less than three months ago, if primary series was the Moderna or Pfizer-BioNTech COVID-19 vaccine; or
    • An individual received an additional dose less than two months ago, if primary series was the Janssen COVID-19 vaccine; or
    • An individual received at least one booster dose after receiving an additional dose.

Here are some examples for each case:

Examples

Examples

Examples

Considered up to date?

Considered up to date?

Considered up to date?

  • Mary received 2 doses of the Moderna COVID-19 vaccine.
  • Mary received one booster dose of the Moderna COVID-19 vaccine 2 months ago.
Examples
  • Mary received 2 doses of the Moderna COVID-19 vaccine.
  • Mary received one booster dose of the Moderna COVID-19 vaccine 2 months ago.

Yes, Mary is up to date with COVID-19 vaccines because she received one booster dose.

Considered up to date?

Yes, Mary is up to date with COVID-19 vaccines because she received one booster dose.

  • Jackie received 2 doses of the Moderna COVID-19 vaccine.
  • Jackie received two booster doses of the Moderna COVID-19 vaccine; last dose was 7 months ago.
Examples
  • Jackie received 2 doses of the Moderna COVID-19 vaccine.
  • Jackie received two booster doses of the Moderna COVID-19 vaccine; last dose was 7 months ago.

Yes, Jackie is up to date with COVID-19 vaccines because she received one booster dose. (In this case, she received two booster doses.)

Considered up to date?

Yes, Jackie is up to date with COVID-19 vaccines because she received one booster dose. (In this case, she received two booster doses.)

  • John received 2 doses of the Moderna COVID-19 vaccine; last dose was 7 months ago.
Examples
  • John received 2 doses of the Moderna COVID-19 vaccine; last dose was 7 months ago.

No, John is not up to date with COVID-19 vaccines because he has not received a booster dose even though he is eligible for it. It has been over 5 months since John received his second dose of the Moderna COVID-19 vaccine. Therefore, John is eligible for a booster dose. He has not yet received a booster dose, so he is not up to date.

Considered up to date?

No, John is not up to date with COVID-19 vaccines because he has not received a booster dose even though he is eligible for it. It has been over 5 months since John received his second dose of the Moderna COVID-19 vaccine. Therefore, John is eligible for a booster dose. He has not yet received a booster dose, so he is not up to date.

  • Tom received 2 doses of the Pfizer-BioNTech COVID-19 vaccine; last dose was 3 months ago.
Examples
  • Tom received 2 doses of the Pfizer-BioNTech COVID-19 vaccine; last dose was 3 months ago.

Yes, Tom is up to date with COVID-19 vaccines. It has been three months since Tom received his second dose of the Pfizer-BioNTech COVID-19 vaccine. Therefore, Tom is not yet eligible for a booster dose at this time (but will be eligible in two months).

Considered up to date?

Yes, Tom is up to date with COVID-19 vaccines. It has been three months since Tom received his second dose of the Pfizer-BioNTech COVID-19 vaccine. Therefore, Tom is not yet eligible for a booster dose at this time (but will be eligible in two months).

  • Jane only received the first dose of the Pfizer-BioNTech COVID-19 vaccine.
Examples
  • Jane only received the first dose of the Pfizer-BioNTech COVID-19 vaccine.

No, Jane is not up to date with COVID-19 vaccines because she did not receive all recommended doses in the primary vaccine series.

Considered up to date?

No, Jane is not up to date with COVID-19 vaccines because she did not receive all recommended doses in the primary vaccine series.

  • Matt received 2 doses of the Moderna COVID-19 vaccine.
  • Matt received an additional dose due to having a severely immunocompromising condition.
  • Matt received one booster dose after the additional dose.
Examples
  • Matt received 2 doses of the Moderna COVID-19 vaccine.
  • Matt received an additional dose due to having a severely immunocompromising condition.
  • Matt received one booster dose after the additional dose.

Yes, Matt is up to date with COVID-19 vaccines because he received a booster dose after the additional dose of his primary series for his immunocompromising condition.

Considered up to date?

Yes, Matt is up to date with COVID-19 vaccines because he received a booster dose after the additional dose of his primary series for his immunocompromising condition.

  • Alice received 2 doses of the Moderna COVID-19 vaccine.
  • Alice received an additional dose one month ago due to having a moderately immunocompromising condition.
  • Alice did not receive any booster doses.
Examples
  • Alice received 2 doses of the Moderna COVID-19 vaccine.
  • Alice received an additional dose one month ago due to having a moderately immunocompromising condition.
  • Alice did not receive any booster doses.

Yes, Alice is up to date with COVID-19 vaccines because she received an additional dose less than three months ago. Therefore, Alice is not eligible for a booster dose at this time (but will be eligible in two months).

Considered up to date?

Yes, Alice is up to date with COVID-19 vaccines because she received an additional dose less than three months ago. Therefore, Alice is not eligible for a booster dose at this time (but will be eligible in two months).

As announced in a press release on May 19, 2022, CDC strengthened its recommendation that certain individuals receive a second booster dose.

Individuals over 50 years of age or those 12 years of age and older who are immunocompromised should now receive a second booster at least four months after the first to remain up to date.

Please refer to guidance here Interim Clinical Considerations for Use of COVID-19 Vaccines | CDC for information on who qualifies for a second booster dose.

NHSN’s surveillance definition of up to date for COVID-19 vaccination data is based on CDC’s clinical considerations and up to date definition for the first day of the reporting quarter.

Please refer to COVID-19 Module: Understanding Key Terms [PDF – 212KB] for definitions of key terms related to COVID-19 vaccination for the purpose of NHSN public health surveillance.

NHSN surveillance definitions are designed to assess trends in the population and inform public health response.

NHSN must be able to standardize criteria and apply these definitions in a consistent manner across populations and time.

For the purpose of surveillance tracking, an NHSN surveillance definition must remain stable for a reporting quarter and will not be updated until the following quarter if CDC’s clinical considerations and up to date definition change.

Data Reporting: Healthcare Personnel

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.

Healthcare personnel eligible to have worked include those scheduled to work in the facility at least one day every week.

For example, an employee who is scheduled to work in the facility every Monday would be included in the data.

However, an employee who is scheduled to work in the facility once a month would not be included in the data.

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.

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.

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 on a regular, weekly basis would not be included.

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.

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

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.

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

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.

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.

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.

Locations and Enrollment

If the facilities are physically separate buildings from each other, whether on the same property or over multiple campuses, then they should be enrolled separately in NHSN.

Each facility should have its own, unique NHSN OrgID.

When a CCN is shared across multiple facilities, the CDC will aggregate the data from all applicable NHSN OrgIDs and will send to CMS under the single CCN for CMS reporting purposes.

Each distinct OrgID should monitor and report COVID-19 vaccination separately, for the purposes of accurate tracking, public health surveillance, and analysis.

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 located within the acute care facility building and sharing the exact same CMS Certification Number [CCN] (100% identical) as the acute care facility. This includes any inpatient rehabilitation ward and inpatient behavioral ward that are not CMS-certified and do not have their own CCN.

Example 1:  Rehabilitation ward within the acute care facility building that shares the same CCN as the acute care facility

  • A rehabilitation ward is not a CMS-certified inpatient rehabilitation facility (IRF) unit and has a CCN of 337766.
  • Acute care facility has a CCN of 337766.
  • The ward resides within the walls of the acute care facility.

Guidance:  Since the rehabilitation ward and acute care facility share the same CCN and are located in the same building, the data for the Enrollment and Reporting for Physically Separate Facilities/Units rehabilitation ward should be combined with the data for the acute care facility and reported through one OrgID.

Include all outpatient units/departments located within the acute care facility building that share the exact same CCN (100% identical) as the acute care facility.

Example 2:  Outpatient department located within the acute care facility building and shares the same CCN as the acute care facility

  • An outpatient radiology imaging department has a CCN of 441122.
  • Acute care facility has a CCN of 441122.
  • The facilities are located in the same building.

Guidance:  Since the radiology imaging department and acute care facility share the same CCN and are located in the same building, the data for this department should be combined with the data for the acute care facility and reported through one OrgID.

If an inpatient or outpatient unit/department of the acute care facility has a different CCN (even if different by only one letter or number) from the acute care facility (such as a CMS-certified inpatient psychiatric unit or inpatient rehabilitation facility), then the CMS-certified unit should be mapped as a unit in the acute care facility and report its data separately.

The unit will share the same OrgID as the acute care hospital, but it will have a separate record reported to NHSN (under its unique CCN and mapped vaccine location).

Example 3:  Inpatient unit within the acute care facility building with a different CCN from the acute care facility.

  • An inpatient behavioral ward that is CMS-certified as an inpatient psychiatric facility (IPF) unit and has a CCN of 55S688 (this unit is located within the acute care facility).
  • Acute care facility has a CCN of 556688.
  • The facilities are located in the same physical building.

Guidance:  The IPF unit should be mapped as unit in the acute care facility in NHSN. Since the IPF unit has a different CCN from the acute care facility, the data for this unit should be reported under the acute care facility NHSN OrgID, but with a separate IPF unit weekly vaccination record.

Facilities can learn more about this topic here: Guidance on Enrollment and Reporting for Physically Separate Facilities/Units* in NHSN (cdc.gov) [PDF – 233KB]

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, and its data should be reported separately.

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

If an inpatient or outpatient unit/department of the acute care facility has a different CCN (even if different by only one letter or number) from the acute care facility (such as a CMS-certified inpatient psychiatric unit or inpatient rehabilitation facility), then the CMS-certified unit should be mapped as a unit in the acute care facility and report its data separately.

The unit will share the same OrgID as the acute care hospital, but it will have a separate record reported to NHSN (under its unique CCN and vaccine location).

Exception: swing beds that reside in their own unit should be reported with the acute care hospital.

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-certified IRF units within the 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.

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.

Data Reporting: Resources

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.

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 healthcare personnel can be used to track the number of healthcare personnel who receive COVID-19 vaccination.

After entering COVID-19 vaccination data for each healthcare personnel 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 “Data Tracking Worksheets” section of the following webpages:

In addition, new Event-level (person-level) COVID-19 Vaccination Forms within the NHSN application are currently available for long-term-care facilities and will soon be available for other facility types.

These forms are enhanced versions of the Excel data tracking worksheets.

For more information on how to use these forms, please see the following question and the section of the FAQs titled “Event-level COVID-19 Vaccination Forms.”

All facilities can submit data in two ways:

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 “CSV Data Import” section of the following webpages:

Long-term care facilities have a third option for data submission.

They can choose to submit data using the event-level (person-level) COVID-19 Vaccination Forms.

These forms are enhanced versions of the Excel documents that have previously been used to submit data.

For more information on how to use the event-level (person-level) vaccination form, please see the following presentation:

Event -Level COVID-19 Vaccination Form Final DSD 032722 (cdc.gov) [PDF – 2.8MB]

This option will be made available to all components later this year.

Facilities are encouraged to report data through NHSN (in addition to any other data reporting systems) because NHSN collects COVID-19 vaccination data at the facility-level.

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.

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

Data Reporting: CSV Upload

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.

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.

Data Reporting: Dialysis Facilities

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.

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

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.

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.

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.

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.

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

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

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.

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.

NHSN has set up auto-confer rights for networks to view weekly COVID-19 vaccination summary reporting for associated outpatient dialysis facilities.

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.

Please note that a facility should decide which of the groups that it has granted access to NHSN for the purpose of viewing their data will upload their data as these same groups will also have access to upload data on their behalf using the .CSV bulk upload process.

If data have been uploaded into NHSN for a facility by one group or supergroup via the .csv bulk upload, these data can be overwritten by a second group uploading data for the facility at a later time or date.

Therefore, NHSN recommends that facilities only grant access to one group/supergroup to upload data on their behalf.

Groups or supergroups can include health departments.

It is also important to note that if a facility has entered its own data, it will not be overwritten by a bulk upload by a group/supergroup.

Reporting COVID-19 Healthcare Personnel Vaccination Data

CMS provides CDC with a list of CMS certification number (CCNs) from which they expect to receive data for required reporting.

CDC then takes that list and extracts the appropriate data from each NHSN facility for CCNs on the CMS list.

Data are ‘frozen’ at midnight on the day of the reporting deadline, and CDC sends data to CMS according to CCN the next business day.

Please contact the programs listed below for specific facility types:

Healthcare personnel (HCP) COVID-19 vaccination summary data submitted to NHSN will be reported by CDC to CMS for each facility by CMS Certification Number (CCN).

For facilities that report more than one week per month, data from the last week of the reporting month will be shared with CMS.

CDC will provide a HCP COVID-19 vaccination percentage for each reporting CCN.

Each quarter, CDC will calculate the quarterly HCP COVID-19 vaccination coverage rates for each facility, by taking the average of the data from the three weekly rates submitted by the facility for that quarter.

This calculation includes data from the core HCP categories of employees, licensed independent practitioners, and adult students/trainees and volunteers who completed a COVID-19 vaccination course.

HCP with NHSN-defined medical contraindications to COVID-19 vaccination are excluded from the denominator.

Tips for submitting COVID-19 vaccination data can be found in the Tips for Submitting Healthcare Personnel (HCP) COVID-19 Vaccination Data [PDF – 249KB]

Review the “COVID-19 Weekly Vaccination Summary” Form that can accessed by clicking on “Vaccination Summary” on the left-hand navigation bar in NHSN.

For complete reporting instructions see: 57.219 Instructions for Completion of the Weekly COVID-19 Vaccination Summary Data Form for Healthcare Personnel (cdc.gov) [PDF – 345KB].

Click “save” after any changes are made to data.

Instructions on how to run a line list report to verify multiple weeks of saved data are available: Weekly COVID-19 Vaccination Reporting – Inpatient Facility – January 2022 [PDF – 580KB].

Data Reporting: Long-term Care Facilities

Long-term care facilities can currently access the NHSN Weekly 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:

You can also find additional information in the SAMS User FAQs published on the SAMS Homepage at https://sams.cdc.gov

Please note that users with level 1 SAMS access will be unable to use the new optional event-level (person-level) COVID-19 vaccination forms to summarize and submit data to the Weekly COVID-19 Vaccination modules.

For more information on how enroll a facility, please see the following webpage: Facility Enrollment | NHSN | CDC.

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.

Newly added question 4.1 and question 4.2 ask the user to report the cumulative number of residents that received both only one booster dose question 4.1) and two more booster doses (question 4.2).

In the above scenario, the individual would be counted in question 2, as having received a complete primary dose, question 4, as having received any additional booster and question 4.2, as having received two or more boosters.

Additionally, based on the current CDC guidance, they would be included in question 5, up to date.

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.

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.

Event-level (Person-Level) Vaccination Reporting: General

No.

The event-level (person-level) COVID-19 Vaccination Forms are an optional tool that can be used to report data to the main weekly HCP and Resident vaccination modules.

Facilities will continue to submit cumulative weekly COVID-19 Vaccination data to the Weekly COVID-19 Vaccination Modules. Data can be reported to these modules in three ways:

  1. Directly into the data entry screens of the COVID-19 Vaccination Modules
  2. Through .CSV upload into the Weekly COVID-19 Vaccination Modules
  3. As of March 28, 2022, long-term care facilities also have the option to use these event-level (person-level) COVID-19 vaccination forms and select the “view reporting summary and submit” button to submit these data to the Weekly Modules.

The event-level (person-level) forms are replacing the optional excel data tracking worksheets previously offered to facilities to assist with reporting to the Weekly COVID-19 Vaccination Modules.

Note that users with level 1 SAMS access will be unable to use the new optional event-level (person-level) COVID-19 vaccination forms to summarize and submit data to the Weekly COVID-19 Vaccination modules.

No.

The optional event-level (person-level) COVID-19 Vaccination Form is a tool that can assist facilities in managing and reporting COVID-19 vaccination data to the main weekly HCW and Resident vaccination modules.

If facilities chose to use this tool, they must select ‘view reporting summary and submit’, select the week of interest and submit data to the COVID-19 Vaccination HCW and Resident Modules at least once per week.

Yes.

Level 3 Access is required to use the optional event-level (person-level) COVID-19 Vaccination Forms.

If you do not see the event-level vaccination forms under the COVID-19 tab, you may not have SAMS Level 3 Access.

To request Level 3 access, please contact the SAMS Help Desk between the hours of 8:00 AM and 8:00 PM EST Monday through Friday (except U.S. Federal holidays) at the following:

The event-level (person-level) COVID-19 Vaccination Form for LTC residents and staff can be used to report data to the Weekly COVID-19 Vaccination Modules beginning with the week of March 28, 2022 – April 3, 2022 and forward.

Users will not have the option to save and submit data for weeks prior to this to the Weekly COVID-19 Vaccination Modules.

Note: If you use the event-level (person-level) form to enter data and click save and submit, it will overwrite data that were previously entered via the summary form and vice versa.

We recommend that facilities chose a single method of data entry for the Weekly COVID-19 Vaccination Modules (1. Data entry into the summary form, 2. CSV upload of the summary form or 3. Use of the event-level forms).

No.

The totals are calculated for you on the summary form, but you still need to review the data, click the “View and Reporting Summary & Submit” button (outlined in a red box below), select the week you want to submit data for, and click “Save and Submit Data”.

You should then confirm that the data saved to the weekly form by checking the calendar view and seeing that the week appears green.

A screenshot showing how to report COVID-19 data.
A screenshot showing how to report COVID-19 data.

You should review data and submit for all weeks affected by updated or newly entered data at least once per week.

Even if you don’t make any changes to the data, you still need to submit once per week.

If you do not submit data for a given week, it will not be shared to the Weekly COVID-19 Vaccination Module.

If during a reporting week, there are no new changes, you should still be sure you review the data and submit at least once per week.

Data are not shared with CMS at the event/person-level.

However, if a facility reports data as part of a CMS Quality Reporting Program, and the facility uses the event-level (person-level) vaccination forms to submit their data to the weekly COVID-19 vaccination module (by selecting “view reporting summary and submit”), then this aggregate (summary) weekly COVID-19 vaccination module data is reported to CMS.

CMS contact information according to facility type are listed below and should be contacted with questions about CMS reporting requirements:

On the event-level (person-level) vaccination form, you should enter the information on the individual’s single dose and on the medical contraindication.

On the reporting summary, you will see that an individual who has a medical contraindication after 1 dose of a 2-dose primary series will be categorized as medical contraindication.

This is consistent with our general guidance for the weekly summary form that if an individual has a severe allergic reaction to the vaccine after 1 dose of a 2-dose primary series, you should classify them as a medical contraindication in accordance with the CDC definition of a contraindication to COVID-19 vaccination.

Yes. Click any column to sort in ascending order. Click the same column again to sort in descending order.

These individuals are counted as declined to receive vaccination. The event-level (person-level) COVID-19 Vaccination form includes a field where you may provide a reason for declination, including religious exemption.

A screenshot showing how to report COVID-19 data.

Event-level (Person-Level) Reporting: Data entry

To add a new Health Care Worker or Resident to the event-level (person-level) COVID-19 Form, please follow the following steps:

  • Step 1: Click + Add Row button
  • Step 2: New yellow section at the top of the form will appear to enter this individual’s data
  • Step 3: Enter required and applicable fields
  • Step 4: Click Save Row

You should report vaccine data on all HCP who are eligible to work in the facility at least once per week; these are the people who “regularly” work in the facility on a weekly basis.

Please see the instructions for question 1 in the table of instructions [PDF – 345KB].

No.

The event-level (person-level) COVID-19 Vaccination Form captures changes in individuals’ vaccination status over time.

If an individual’s vaccination status changes, add the new status date to the existing row, and do not delete the old status.

For example, a resident who was recently admitted was offered the COVID-19 vaccine and initially declined on 3/1/2022.

The resident later decided to get vaccinated on 3/6/2022.

Add the new COVID-19 vaccine data to the existing row but do not delete the initial declined date of 3/1/2022.

This allows us to capture the data accurately over time.

Previously saved records can be updated directly in the NHSN event-level (person-level) forms by clicking the cell that needs to be updated and enter the changes directly into the grid of the record.

Note: Be sure to click out of the cell(s) modified and then click “view reporting summary and submit” to share the new information for all weeks impacted by a change to the Weekly COVID-19 Vaccination Modules.

If you do not click “view reporting summary and submit” and save and submit for all modified weeks, this modified information will not be reflected in the Weekly COVID-19 Vaccination Modules.

If HCP goes on leave and returns to work in 2 weeks (14 days) or less, nothing on their row needs to be changed, and their information can continue to be maintained on the original row.

If the HCP goes on leave for longer than 2 weeks (14 days) and returns to work after more than 2 weeks, you should enter an end date on the day they begin leave.

When they return to work, you should duplicate their row (using the + button next to their row) and enter a new start date on their new row.

The new start date on the new row is the day they return to work.

Note: This is consistent with our guidance for the weekly summary forms that says to continue including HCP on temporary leave (2 weeks or less) and to exclude HCP if their leave is longer than 2 weeks.

A screenshot showing how to report COVID-19 data.

If the resident is discharged or leaves the facility for any reason, and then returns or is re-admitted within 1 week (7 days) or less, nothing on their row needs to be changed, and their information can continue to be maintained on the original row.

If the resident is discharged or leaves the facility for any reason for longer than 1 week (7 days) and returns or is re-admitted after more than 1 week, you should enter a discharge date on the day they were discharged or left.

When they return or are re-admitted, you should duplicate their row (using the + button next to their row) and enter a new admission date on their new row.

Note: This is consistent with our guidance for the weekly summary forms that says to count all residents occupying a bed at this facility for at least 1 day (at least 24 hours) during the week of data collection.

A screenshot showing how to report COVID-19 data.

No. If data is entered and saved, the row cannot be deleted. It is recommended that you do one of the following:

Edit the row/ repurpose the row with someone else’s data or

Change the discharge/end date to a date that is before the event-level forms can be used to submit date (i.e., before 3/28/2022). This way, the incorrect individual won’t contribute to any data that can be submitted.

Note: If you do this, you should also change the name and ID to avoid confusion. Also, add a note to the “Comments” column on the far right to document that this entry is incorrect.

A computer screenshot showing the comment section of the application for uploading reporting data.

Yes.

It is encouraged that you use the same identifier for individuals throughout the NHSN application, and that each individual has a UNIQUE identifier.

First, you will click ‘Upload CSV’.

Second, you will click ‘Browse’ to locate the saved file.

Third, once the selected file is visible in the Browse box, you will then click the ‘Upload CSV’ button.

A computer screenshot showing the upload CSV section of the application for uploading reporting data.

  1. Make sure you are on the tab called “Tracking Worksheet”
  2. Ensure your data in Excel are up to date
  3. Select the most recent week with updated data from the reporting week drop down
  4. Click File
  5. Click “Save as” or “Save a Copy”
  6. Select the file type of “CSV UTF-8 (Comma delimited) or CSV (Comma delimited)”
  7. Click “Save”
  8. The box below will appear. Click OK
A computer screenshot showing error message after uploading reporting data.

Note: After the May 30th release, you should not upload Excel Data Tracking Worksheets because key variables, such as second booster doses, are not included in the Excel Data Tracking Worksheets.

No.

It is important that you only upload the Excel worksheet once because there are key differences between the Excel worksheet and the NHSN event-level (person-level) Vaccination Forms.

Uploading more than once could lead to inaccurate data in NHSN over time.

Note: After the May 30th release, you should not upload Excel Data Tracking Worksheets because key variables, such as second booster doses, are not included in the Excel Data Tracking Worksheets.

Individuals are counted as unknown vaccination status in the following circumstances:

  1. The individual is listed as unknown vaccination status.
  2. The individual has only one dose of an unknown/unspecified manufacturer. This individual is categorized as unknown vaccination status because it is unclear if this single unspecified dose represents a partial or complete primary series.
  3. The individual has a gap between their start date and the first status date that is entered, such as start date 1/1, declined on 2/3. The individual will be categorized as unknown vaccination status from 1/1 to 2/2.