District: State/Province: Country: Date of visit: Date of last visit:Surveillance 1a. Total number of patients seen at this health facility in the previous month # 1b. Number of patients screened on entrance to this health facility for COVID-19 symptoms in the previous month 1c. Number of suspected COVID-19 patients reported to local surveillance personnel from this health facility in the previous month 2a. Number of unique2 health care workers (HCWs) who reported to work at this health facility in the previous month 2b. Number of new suspected COVID-19 infections among HCWs at this health facility in the previous month 2c. Number of new confirmed COVID-19 infections among HCWs at this health facility in the previous month 2d. Does the facility have an assessment and management protocol in place (including a register, assessment tools, communication, etc.) for exposed or confirmed HCWs?
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