Facility ID:
*Location Code:
*Month:
*Year:
Date
*Number of patients
**Number of patientswith 1 or morecentral lines (if patient has both, count as Temporary)
**Number of patientswith aurinary catheter
**Number of patientson aventilator
Temporary
Permanent
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*Totals
Patient-days
Temporary CL-days
Permanent CL-days
Urinary catheter-days
Ventilator-days
Label
__________
Data