Form CDC 57.101 CDC 57.101 Facility Contact Information

The National Healthcare Safety Network (NHSN)

57.101_FacConInf_BLANK.ppt

57.101_Facility Contact Information

OMB: 0920-0666

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  1. * required for saving

  1. Tracking #:

  1.        

  1. *Facility Name:

  1. *Main Telephone Number:

 

  1. *Mailing Address:

  1. *City:

  1. *County:

  1. *State:

  1. *ZIP:           -

 

  1. For each identifier listed below, enter the # / code or check “Not Applicable” if your facility does not have that identifier:

  1. *American Hospital Association ID#:

  1.      Not Applicable

  1. *CMS Certification Number (CCN):

  1.      Not Applicable

  1. *VA Station Code:

  1.      Not Applicable

  1. If none of the above identifiers is applicable, enter CDC-provided Enrollment #:

  1. *Facility Type:

  1. *Was this facility operational in the survey year?           YES           NO

  1. *NHSN Components:
    Indicate which component(s) the Facility will use initially (components may be added at any time after enrollment)

 

  1. Patient Safety Component                          

 

  1. Healthcare Personnel Safety Component

 

  1. Biovigilance Component

  1. NHSN Facility Administrator:

  1. *Name:

  1. Title:

  1. *Mailing Address: (if different from facility)

                            ___________________________________________________

                            ___________________________________________________

                            ___________________________________________________

  1. *City:

  1. *State:

  1. *ZIP:           -

  1. *Telephone Number:(     )

  1. Extension:

  1. FAX Number:(     )

 

  1. Pager Number:(     )

 

  1. *Email:

 

  1. *User Name:  

  1. Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

    Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).

    CDC 57.101 (Front) Rev. 4, v6.4

 

  1. NHSN Patient Safety Primary Contact Person (if different from Facility Administrator)

  1. *Name:

  1. Title:

 

  1. *Mailing Address: (if different from facility)__________________________________________

                            ___________________________________________________

                            ___________________________________________________                        

  1. *City:

 

  1. *State:

  1. *ZIP:         -

 

  1. *Telephone Number:(     )

  1. Extension:               FAX Number:(     )

  1. Pager Number: (     )

  1. *Email:

  1. NHSN Healthcare Personnel Safety Primary Contact Person (if different from Facility Administrator)

  1. *Name:

  1. Title:

  1. *Mailing Address: (if different from facility)__________________________________________

                            ___________________________________________________

                            ___________________________________________________

  1. *City:

  1. *State:

  1. *ZIP:           -

  1. *Telephone Number:(     )

  1. Extension:               FAX Number:(     )

  1. Pager Number:(     )

  1. *Email:                         Valid email account required for enrollment

  1. Microbiology Laboratory Director/Supervisor (if different from Facility Administrator)

  1. *Name:

  1. Title:

  1. *Mailing Address: (if different from facility) _________________________________                                          

                            ___________________________________________________

                            ___________________________________________________                        

  1. *City:

  1. *State:

  1. *ZIP:           -

  1. *Telephone Number:(     )

  1. Extension:                FAX Number:(     )

  1. Pager Number:(     )

  1. *Email:                         Valid email account required for enrollment

  1. Biovigilance Primary Contact  (if different from Facility Administrator)

  1. *Name:  

  1.        

  1. Title:

  1. *Mailing Address: (if different from facility)  ________________________________________                            

  1.                         ___________________________________________________

  1.                         ___________________________________________________

  1. *City:

  1. *State:

  1. *ZIP:           -

  1. *Telephone Number:(     )

  1. Extension:                FAX Number:(     )

  1. Pager Number:(     )

  1. *Email:                          Valid email account required for enrollment

  1. CDC 57.101 (Back) Rev. 4, v6.4

 
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File TitleSlide 1
AuthorCDC
Last Modified Byano3
File Modified2010-08-16
File Created2004-07-27
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