COVID-19 Long Term Care facility data collection forms

Dear Mr. Welsh. Please find the attached document and information in
response to your request for forms used to compile Covid-19 cases, deaths
and outbreaks at long-term care facilities.

A word document of the form used to collect information for all COVID-19
cases is attached. The form is formatted differently in Domo, but the
question that captures if a case works at a LTC facility is in the
'Work/School' section and if a case lives in a LTC facility is in the
'Household' section. Both sections have a question for the 'LTC Facility
Name' that is pre-populated with the Iowa LTC facilities. Screenshots of
the questions as they appear in Domo are provided below. All of the other
information captured on the form is the same for all COVID-19 cases.

*Work/School: LTC staff questions*
[image: image.png]
*Household: LTC resident questions*
[image: image.png]
[image: image.png]

All COVID-19 deaths are tracked by Vital Records. However, Vital Records
doesn't know that the decedent is a resident of a LTC when the death is
reported.

Please let us know if you have any questions.

Thanks!

--
Open Records
Iowa Department of Public Health

---------- Forwarded message ---------
From: <requests@muckrock.com>
Date: Wed, Oct 27, 2021 at 9:21 PM
Subject: Iowa Open Records Law Request: COVID-19 Long Term Care facility
data collection forms
To: <RERC@idph.iowa.gov>

Department of Public Health
ORA Office
321 East 12th Street
Des Moines, IA 50319-0075

October 27, 2021

To Whom It May Concern:

Pursuant to the Iowa Open Records Law, I hereby request the following
records:

All of the forms used to collect data on COVID-19 cases, deaths and
outbreaks at long term care facilities.

The requested documents will be made available to the general public, and
this request is not being made for commercial purposes.

In the event that there are fees, I would be grateful if you would inform
me of the total charges in advance of fulfilling my request. I would prefer
the request filled electronically, by e-mail attachment if available or
CD-ROM if not.

Thank you in advance for your anticipated cooperation in this matter. I
look forward to receiving your response to this request within 10 business
days, as the statute requires.

Sincerely,

Ben Welsh

View request history, upload responsive documents, and report problems here:
https://www.muckrock.com/

Filed via MuckRock.com
E-mail (Preferred): requests@muckrock.com

For mailed responses, please address (see note):
MuckRock News
DEPT MR 120672
411A Highland Ave
Somerville, MA 02144-2516

PLEASE NOTE: This request is not filed by a MuckRock staff member, but is
being sent through MuckRock by the above in order to better track, share,
and manage public records requests. Also note that improperly addressed
(i.e., with the requester's name rather than "MuckRock News" and the
department number) requests might be returned as undeliverable.

*Protecting and improving the health of Iowans*

--
This email message and its attachments may contain confidential information
that is exempt from disclosure under Iowa Code chapters 22, 139A, and other
applicable law. Confidential information is for the sole use of the
intended recipient. If you believe that you have received this transmission
in error, please reply to the sender, and then delete all copies of this
message and any attachments. If you are not the intended recipient, you are
hereby notified that any review, use, retention, dissemination,
distribution, or copying of this message is strictly prohibited by law.