Form 57.121 Denominator for Procedure

Facility ID:		Procedure #:
*Patient ID:		Social Security #:
Secondary ID:
Patient Name, Last:                                      First:                                           Middle:
*Gender:     F     M		*Date of Birth:
Ethnicity (specify):		Race (specify):
Event Type: PROC		*NHSN Procedure Code:
*Date of Procedure:		ICD-9-CM Procedure Code:
Risk Factors
*Outpatient:    Yes     No                               Surgeon Code:_______________________ *ASA Score:   1     2     3     4     5                   *Duration: _____hours   _____minutes     *Wound Class:  C     CC     CO     D           *Diabetes Mellitus:   Yes     No *Height: ____ feet _____inches                       *Weight: _____ lbs / kgs (circle one)          or  ____ meters (choose one)
When NHSN Proc Code is one of those listed below, circle  the code and complete additional risk factor(s)	Additional Risk Factors
AAA   CHOL  HER   NEPH REC  VHYS	*Endoscope:    Yes     No                *Implant:    Yes    No
APPY	*Emergency:   Yes    No                 *Endoscope:    Yes    No
BILI   OVRY   PRST   SB THOR   XLAP	*Endoscope:   Yes    No
BRST  CEA  PVBY  VSHN	*Implant:    Yes    No
CARD  LTP	*Emergency:   Yes     No
CBGB	*Endoscope (for CBGB donor site only):  Yes    No
COLO  LAM	*Endoscope:    Yes     No                 *Implant:    Yes    No     *General Anesthesia:   Yes     No
CRAN	*Trauma:   Yes     No                       *Implant:    Yes    No
CSEC	*Emergency:    Yes   No                   *General Anesthesia:   Yes     No *Duration of Labor: _____hours
GAST	*Emergency:   Yes     No               *Endoscope:    Yes     No *Implant:    Yes    No
HPRO  KPRO	*General Anesthesia:   Yes     No      *Trauma:   Yes     No *Check one:   ____Total   ____Hemi   ____ Resurfacing (HPRO only)      If Total: ____Primary   ____Total Revision   ____Partial Revision      If Hemi:  ____Primary   ____Total Revision   __ _ Partial Revision      If Resurfacing (HPRO only) :  ____Primary Total      ____Revision Total                                                  ____Primary Partial    ____Revision Partial
HYST	*Endoscope:   Yes   No                     *General Anesthesia:   Yes     No
Continued > > > 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 57.121 (Front) Rev. 4, v6.4

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When NHSN Proc Code is one of those listed below, circle the code and complete additional risk factor(s)	Additional Risk Factors
FUSN   RFUSN	*Spinal Level: (check one)          Atlas-axis          Atlas-axis/Cervical          Cervical          Cervical/Dorsal/Dorsolumbar           Dorsal/Dorsolumbar          Lumbar/Lumbosacral          *Implant:   Yes    No		*Approach/Technique: (check one)          Anterior          Posterior          Anterior and Posterior          Lateral transverse         *Trauma:   Yes     No
Custom Fields
Label ________________________   ___/___/____ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________ ________________________   ___________		Label   ________________________   ___/___/____     ________________________   ___________     ________________________   ___________     ________________________   ___________     ________________________   ___________   ________________________   ___________     ________________________   ___________
Comments
CDC 57.121 (Back)  Rev. 4, v6.4

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