Use This Census Template » Upload Your Completed Census »

The template includes the required fields of: Resident Last Name, Resident First Name, Date of Birth, Admission Date, Room Number, Short-Stay Y/N, Representative Last Name, Representative First Name, Representative Address, Representative State, Representative ZIP, Representative Phone Number, Uninvolved Rep Y/N.

Upload two weeks before your scheduled interview date.

Do not exclude any resident for any reason, including length of stay, physical condition, or cognitive ability. Learn more about interviewing residents with dementia and/or cognitive impairment.

Short-stay residents are defined as residents whose intended length of stay is 30 days or less (the actual length of stay may be longer). No Resident Representative information is needed for short-stay residents.

A resident representative is someone who is familiar with the resident’s care and can answer questions about it. This person may be a family member, friend, or guardian. The representative does not necessarily make decisions for the resident. Residents are not eligible to complete the family survey.

Please note: Resident name, date of birth, and admission date are used for quality assurance purposes, as well as matching the collected survey data to MDS for risk adjustment.

In accordance with HIPAA and the HITECH Act, all resident census lists must be submitted using our secure upload link. Do not email any resident information.