Form 57.203 Healthcare Personnel Safety Reporting Plan

The National Healthcare Safety Network (NHSN)

57.203_HCPSafetyPlan_BLANK.ppt

57.203 Healthcare Personnel Safety Reporting Plan

OMB: 0920-0666

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  1. Facility ID#:_______________________                 *Month/Year:_______/_______

  1.   No NHSN Healthcare Personnel Safety Modules followed this month

  1. Healthcare Personnel Exposure Modules

  1.   Blood/Body Fluid Exposure Only

      Blood/Body Fluid Exposure with Exposure Management

      Influenza Exposure Management

  1. Healthcare Personnel Vaccination Module

  1.   Influenza Vaccination with Exposure Management/Treatment

   
  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 57.203, v6.4

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

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