COVID-19 Long-term care facility staff vaccination

COVID-19 Long-term care facility staff vaccination – Executive Order 13F

* - Required Field

General Information

1. Facility Type

2. Facility Name

3. First name of person submitting this report*

4. Last name of person submitting this report*

5. Title of person submitting this report*

6. Phone Number of person submitting this report*

7. Email of person submitting this report *

8. Date of report/submission date*

Facility Information

Note: The total number of Covered LTC Workers reported in Question 9 should EQUAL the total number of individuals identified in Questions 10a through 10e.

9. As of this date, provide the total number of “Covered LTC Workers” in your “long-term care facility” as these terms are defined in Executive Order 13B.*

10. As of this date, provide the number of Covered LTC Workers who:

10.a. Are fully vaccinated against COVID-19 (at least 14 days have elapsed since a person has received the final dose of a COVID-19 vaccine).*

10.b. Received the first dose and has either received a second dose or has an appointment for the second dose in a two-dose series vaccination, such as Pfizer or Moderna vaccines, or has received a single-dose vaccine, such as Johnson & Johnson’s Janssen vaccine.*

10.c. Provided documentation from a physician, physician’s assistant, or advanced practice registered nurse stating that the administration of COVID-19 vaccine is likely to be detrimental to the individual’s health.*

10.d. Provided documentation of their objection to vaccination on the basis of a sincerely held religious belief.*

10.e. Number of Covered LTC Workers who do not fall within the foregoing categories.*

* I warrant and declare under penalty of perjury that the information included in this report is accurate. Submission of a false statement to the Department of Public Health is subject to the criminal penalties of false statement pursuant to Conn. Gen. Stat. § 19a-500 and § 53a-157b.

* I am authorized to submit this information on behalf of my facility.

DEPARTMENT OF PUBLIC HEALTH

DPH FLIS - Facility Licensing & Investigations Section(FLIS)

COVID-19 Long-term care facility staff vaccination – Executive Order 13F

General Information

Facility Information

Note: The total number of Covered LTC Workers reported in Question 9 should EQUAL the total number of individuals identified in Questions 10a through 10e.

If you are reporting 0 covered LTC workers for your facility because you included those workers in the compliance report of an affiliated facility, please indicated which facility type and facility name here: