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Please submit the following information ONLY ONCE PER MONTH ON THE DUE DATE 

PLEASE DO NOT SUBMIT MORE THAN ONE SURVEY PER FACILITY PER MONTH. 

THE DUE DATES FOR SURVEYS FOR THE REST OF 2022:

09/06/2022 (COVERING 08/07/2022-09/03/2022)
10/03/2022 (COVERING 09/04/2022-10/01/2022
11/07/2022 (COVERING 10/02/2022-11/05/2022)
12/05/2022 (COVERING 11/06/2022-12/03/2022)


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* 1. Please identify the reporting date you are submitting responses for?

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* 2. Facility Information

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* 4. Facility Type

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* 5. Are you submitting survey results for more than one facility? (YES or NO)  If YES, please indicate which facilities below:

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* 6. How many residents TESTED positive (regardless of when they resulted) within the time period IDENTIFIED IN QUESTION 1 (August 07, 2022-September 03, 2022 )

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* 7. How many staff TESTED positive (regardless of when they resulted) within the time period IDENTIFIED IN QUESTION 1 
(August 07, 2022-September 03, 2022) :

(ONLY ENTER TODAY'S DATE IF YOU ACTUALLY HAVE A  POSITIVE INDIVIDUAL THAT HAPPEND TO TEST TODAY) 

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* 8. What is the TEST DATE  of your most recent positive staff or resident?

(ENTER THE MOST RECENT POSITIVE TEST DATE EVEN IF IS OUTSIDE THE DATE RANGE REFERRED TO IN QUESTION 1)

Date

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* 9. How many residents who have been diagnosed with COVID-19  have expired since AUGUST 7, 2022

If you have any questions or need to speak with the LTC Rapid Response Team, please email Michael.Miller3@state.nm.us or 505-377-5792
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