{"text_format":"1","workbook":"xlsx","n_sheets":3,"sheets":["PLEASE READ-Instructions","Tracking Worksheet","Vaccination Summary"],"not_rendered":{"charts":0,"images":0,"macros":0,"external_links":1,"defined_names":1,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"PLEASE READ-Instructions","index":0,"n_rows":33,"n_cols":4,"rows_kept":33,"cut":false,"hidden":false,"merged":[[22,3,22,9],[26,3,26,9],[8,1,8,9],[9,1,9,9],[10,1,10,9],[11,1,11,9],[12,1,12,9],[7,1,7,9],[2,1,2,9],[3,1,3,9],[5,1,5,9],[6,1,6,9],[4,1,4,9],[30,1,30,9],[31,1,31,9],[32,1,32,9],[28,3,28,9],[27,3,27,9]]}
[]
[]
[null,"Instructions  (MDPH Version 1.0, June 2021)"]
[]
[null,"Purpose of this Tracking Worksheet:"]
[null,"Please use this worksheet to help log and track the COVID-19 vaccination status for residents. When you enter COVID vaccination data for each resident in the 'Tracking Worksheet' tab, and select a reporting week, the data needed for reporting into NHSN will be automatically calculated in the 'Vaccination Summary' tab. "]
[null,"Summary Instructions:"]
[null,"Any residents admitted to your facility should be added to the 'Tracking Worksheet' tab.  When residents are vaccinated, enter the vaccination information (type and date) into the 'Tracking Worksheet'.  If a resident has a medical contraindication, declines vaccine, or has an unknown vaccination status, this information should be documented appropriately in the worksheet.  When residents are discharged, enter the discharge date into the 'Tracking Worksheet'. \n\nNOTE: Residents who are discharged do not need to be deleted off the 'Tracking Worksheet' but should be entered on the worksheet by entering the Resident Discharge Date. When a reporting week is selected, only those who were current residents during the reporting period will be included in the 'Vaccination Summary'.  \n\nIf data entries are made in error, they can be removed using the \"delete\" key. Using the \"Backspace\" key may not delete the entry and may return a warning."]
[null,"Detailed Instructions:"]
[null,"NOTE: In order for this spreadsheet to operate at 100%, please ENABLE MACROS and save as \"Excel Macro Enabled Workbook\""]
[null,"A. The red Asterix (*) is required for reporting to NHSN. Note: The other boxes are for optional NHSN reporting "]
[null,"B. Enter data in rows (from left to right) when entering vaccine data for each resident"]
[null,"C. Steps for Entering Resident Vaccination Data on the 'Tracking Worksheet' tab:"]
[null,null,1,"Enter the unique (Facility ID#) for the reporting facility"]
[null,null,2,"Select the (*First Day of the Reporting Week) that you plan to generate the report (Note: the first day of the reporting week is always a Monday)"]
[null,null,3,"Enter the (*Resident Admit Date) to the facility. A date must be entered. If unknown choose a date before the first reporting week (e.g., 12/1/2020)"]
[null,null,4,"Enter the (*Resident Discharge Date) from the facility (when applicable)"]
[null,null,5,"Enter resident’s first name, last name, DOB (date of birth) or Other identifier"]
[null,null,6,"Select (*Dose 1 Vaccine Name) from the drop-down box "]
[null,null,7,"Enter date the resident was vaccinated with dose 1  (*Vaccinated with Dose 1)"]
[null,null,8,"The vaccine name for the second dose will automatically populate based on the vaccine name selected for the first dose (Dose 2 Vaccine Name)"]
[null,null,9,"Enter date the resident was vaccinated with Dose 2 (*Vaccinated with Dose 2)"]
[null,null,10,"Select 'YES' if the resident (*Completed COVID vaccine series with unspecified manufacturer), do not enter vaccine doses in the prior sections"]
[null,null,11,"Select 'YES' (*Medical contraindication), if applicable "]
[null,null,12,"Select 'YES' (*Declined vaccine), if applicable"]
[null,null,13,"Select 'YES' (*Unknown Vaccine Status), if applicable.  This would include residents pending vaccination. "]
[null,null,14,"Select YES/NO if the resident was vaccinated at another location (optional)"]
[null,null,15,"Enter any additional comments (optional)"]
[null,null,16,"Click on the \"Reporting Summary\" tab to see data to be entered into NHSN for the reporting week."]
[]
[null,"IMPORTANT **DO NOT send this form to NHSN, this form is to ONLY be used by your facility for COVID vaccine data collection and record keeping purposes**"]
[]
[null,"Please refer to the TOI (Table of Instructions) for further details on NHSN reporting at https://www.cdc.gov/nhsn/ltc/weekly-covid-vac/index.html"]

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[]
[null,"Weekly COVID-19 Vaccination Cumulative Summary ",null,null,null,null,"Facility ID#:",null,null,null,"   Enter your Facility ID Here"]
[null,"for Residents of Long-Term Care Facilities",null,null,null,null,"Vaccination type:",null,null,"COVID_19"]
[null,"TRACKING WORKSHEET",null,null,null,null,null,null,"*First day of Reporting Week (Monday):","2021-05-24","   Select the Monday of the start of the week you are reporting"]
[null,null,null,null,null,null,"Last day of the reporting week (Sunday):",null,null,{"$f":"IF(ISBLANK(J4),\"-\",J4+6)","v":"2021-05-30"},"   Last day of the reporting week automatically populated"]
[null,"* Required fields"]
[]
[null,"*Resident Admit Date","*Resident Discharge Date \n(if applicable)","Resident \nLast Name","Resident \nFirst Name ","Unique Patient Identifier \n(Enter DOB, Med Record #, etc.)","*Dose 1 \nVaccine Name \n(choose from drop-down)","*Dose 1 \nVaccine Date","Dose 2\nVaccine Name \n(automatically populated)","*Dose 2\nVaccine Date","Completed COVID vaccine series with unspecified manufacturer?","*Medical contraindication to COVID Vaccine?","*Declined COVID Vaccine?","*Unknown Vaccine Status (including those pending vaccination)?","Vaccinated at Another Location?\nSelect: Yes/No","Additional Comments",null,"1. Residents",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4)","v":0}]
[null,null,null,null,null,null,null,null,{"$f":"IF(G9=\"Pfizer-BioNTech\",\"Pfizer-BioNTech\",IF(G9=\"Moderna\",\"Moderna\", IF(G9=\"Janssen\",\"\",\" \")))","v":" "},null,null,null,null,null,null,null,null,"2.1 1 Pfizer",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Pfizer-BioNTech\",$J$9:$J$1007,\"\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Pfizer-BioNTech\",$J$9:$J$1007,\"\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"2.2 2 Pfizer",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$I$9:$I$1007,\"Pfizer-BioNTech\",$J$9:$J$1007,\"<>\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$I$9:$I$1007,\"Pfizer-BioNTech\",$J$9:$J$1007,\"<>\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"2.3 1 Moderna",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Moderna\",$J$9:$J$1007,\"\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Moderna\",$J$9:$J$1007,\"\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"2.4 2 Moderna",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$I$9:$I$1007,\"Moderna\",$J$9:$J$1007,\"<>\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$I$9:$I$1007,\"Moderna\",$J$9:$J$1007,\"<>\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"2.5 Janssen",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Janssen\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Janssen\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"2.99 Unspecified",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$K$9:$K$1007,\"YES\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$K$9:$K$1007,\"YES\")","v":0}]
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[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"3.1 Medical",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$L$9:$L$1007,\"YES\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$L$9:$L$1007,\"YES\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"3.2 Declined",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$M$9:$M$1007,\"YES\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$M$9:$M$1007,\"YES\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"3.3 Unknown",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$N$9:$N$1007,\"YES\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$N$9:$N$1007,\"YES\")","v":0}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"3.4 History oF COVID",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",#REF!,\"YES\")+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,#REF!,\"YES\")","v":{"$error":"#REF!"}}]
[null,null,null,null,null,null,null,null," "]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"5.1. Pfizer",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Pfizer-BioNTech\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Pfizer-BioNTech\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)","v":{"$error":"#REF!"}}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"5.2 Moderna",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Moderna\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Moderna\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)","v":{"$error":"#REF!"}}]
[null,null,null,null,null,null,null,null," ",null,null,null,null,null,null,null,null,"5.3 Janssen",{"$f":"COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\"\",$G$9:$G$1007,\"Janssen\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)+COUNTIFS($B$9:$B$1007, \"<=\"&J5,$C$9:$C$1007,\">=\"&J4,$G$9:$G$1007,\"Janssen\",#REF!,\">=\"&J4,#REF!,\"<=\"&J5)","v":{"$error":"#REF!"}}]
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{"sheet":"Vaccination Summary","index":2,"n_rows":27,"n_cols":3,"rows_kept":27,"cut":false,"hidden":false,"merged":[[22,1,22,2],[1,1,1,2],[2,1,2,2],[9,1,9,2],[11,1,11,2],[18,1,18,2]]}
[]
[null,"Weekly COVID-19 Vaccination Cumulative Summary for Residents of Long-Term Care Facilities"]
[null,"TRACKING WORKSHEET"]
[]
[null,"Facility ID#:",{"$f":"'Tracking Worksheet'!J2","v":0}]
[null,"Vaccination type: COVID-19 ",{"$f":"'Tracking Worksheet'!J3","v":"COVID_19"}]
[null,"Week of data collection first day (Monday): ",{"$f":"'Tracking Worksheet'!J4","v":"2021-05-24"}]
[null,"Week of data collection last day (Sunday): ",{"$f":"'Tracking Worksheet'!J5","v":"2021-05-30"}]
[null,"Date Last Modified:",{"$f":"TODAY()","v":"2021-06-02"}]
[null,"Cumulative Vaccination Coverage"]
[null,"1. *Number of residents staying in this facility for at least 1 day \n     during the week of data collection ",{"$f":"'Tracking Worksheet'!S8","v":0}]
[null,"2. *Cumulative number of residents in Question #1 who have received COVID-19 \n     vaccine(s) at this facility or elsewhere:   "]
[null,"2.1. Only dose 1 of Pfizer-BioNTech COVID-19 vaccine ",{"$f":"'Tracking Worksheet'!S9","v":0}]
[null,"2.2. Dose 1 and dose 2 of Pfizer-BioNTech COVID-19 vaccine",{"$f":"'Tracking Worksheet'!S10","v":0}]
[null,"2.3. Only dose 1 of Moderna COVID-19 vaccine ",{"$f":"'Tracking Worksheet'!S11","v":0}]
[null,"2.4. Dose 1 and dose 2 of Moderna COVID-19 vaccine",{"$f":"'Tracking Worksheet'!S12","v":0}]
[null,"2.5. Dose of Janssen COVID-19 vaccine",{"$f":"'Tracking Worksheet'!S13","v":0}]
[null,"2.99. Complete COVID-19 vaccination series: unspecified manufacturer",{"$f":"'Tracking Worksheet'!S14","v":0}]
[null,"3. Cumulative number of residents in Question #1 with other conditions:"]
[null,"3.1. Medical contraindication to COVID-19 vaccine",{"$f":"'Tracking Worksheet'!S16","v":0}]
[null,"3.2. Offered but declined COVID-19 vaccine",{"$f":"'Tracking Worksheet'!S17","v":0}]
[null,"3.3. Unknown COVID-19 vaccination status",{"$f":"'Tracking Worksheet'!S18","v":0}]
[null,"COVID-19 Vaccine(s) Supply"]
[null,"4.1. Is your facility enrolled as a COVID-19 vaccination provider?"]
[null,"4.2. Did your facility have a sufficient supply of COVID-19 vaccine(s) to \n        offer all residents the opportunity to receive COVID-19 vaccine(s) \n        from your facility in the current reporting week?"]
[null,"4.3. Did your facility have other arrangements sufficient to offer all \n        residents the opportunity to receive COVID-19 vaccine(s) in the \n        current reporting week (examples of other arrangements include \n        referring to the health department or pharmacies for vaccination)?"]
[null,"4.4. Please describe any other COVID-19 vaccination supply-related \n        issue(s) at your facility. \n        [Optional]"]