Form CDC 57.200 CDC 57.200 Healthcare Personnel Safety Component Annual Facility Su

The National Healthcare Safety Network (NHSN)

57.200_AnnualFacSurv_BLANK.ppt

57.200_Healthcare Personnel Safety Component Facility Survey

OMB: 0920-0666

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  1. Tracking#:________________________

  1. Facility ID#:_______________________                 *Survey Year:__________

  1. Enter Selected Healthcare Worker Occupational Groups on page 2.

  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 8 hours 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 57.200 (Front), v6.4

 
 
  1. CDC 57.200 (Back), v6.4

  1. *Selected Healthcare Worker Occupational Groups

  1. Occupation

  1. Number of HCWs

  1. Number of FTEs

  1. Registered nurse

  
  1. Licensed practical nurse

  
  1. Nurse practitioner/clinical nurse specialist

  
  1. Nursing assistant/patient care technician

  
  1. Nurse midwife

  
  1. Nurse anesthetist

  
  1. Attendant/orderly

  
  1. Respiratory technician/therapist

  
  1. Phlebotomist

  
  1. IV team

  
  1. Medical laboratory technician

  
  1. OR/surgical technician

  
  1. Dental assistant/technician

  
  1. Dental hygienist

  
  1. Dentist

  
  1. Housekeeper

  
  1. Laundry staff

  
  1. Maintenance/engineering service

  
  1. Central supply staff

  
  1. Physician assistants

  
  1. Intern/resident

  
  1. Fellow

  
  1. Attending physician

  

 
File Typeapplication/vnd.ms-powerpoint
File TitleSlide 1
AuthorCDC
Last Modified Byano3
File Modified2010-08-04
File Created2004-07-27

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