* required for saving
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Facility ID:
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Facility Characteristics
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*Ownership (check one):
□ For profit □ Not for profit, including church □ Government □ Military □ Veteran’s Affairs □ Physician owned □ Managed Care Organization
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If facility is a Hospital: *Number of Patient Days: _________ *Number of Admissions: _________
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For any Hospital except Long Term Acute Care Hospitals:
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*Is your hospital affiliated with a medical school? : Yes No
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If Yes, what type of affiliation: ____ MAJOR ____ GRADUATE ____ LIMITED
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Number of beds set up and staffed: a. ICU beds (including adult, pediatric, and neonatal levels II/III and III): ___________ b. Specialty care beds (including hematology/oncology, bone marrow transplant, solid organ transplant, inpatient dialysis, and long term acute care [LTAC]): ___________ c. All other beds: ___________
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For Hospitals that are Long Term Acute Care (LTAC): No LTAC or not operational in this survey year Setting: ___ Within a hospital ___ Free-standing Number of beds set up and staffed: a. Ventilator beds: ___________ b. High-observation beds: ___________ c. All other beds: ___________
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If facility is an Ambulatory Surgery Center (ASC): No ASC or not operational in this survey year Setting: ___ Within a hospital ___ Free-standing Total number of procedures: ________ Percent of procedures that are surgical: ________ % What percentage of your ambulatory surgery patients were discharged or transferred to the following places: Home/Customary residence: _______% Recovery care center (facility other than this one): _______ % Acute care hospital (Emergency or inpatient): _______ %
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If facility is a Long Term Care (LTC) Facility: No LTC or not operational in this survey year Number of resident days: ______ Average length of stay: ___________
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Infection Control Practices *Number of infection preventionists (IPs) in facility: __________ a. Total hours per week performing surveillance: __________ b. Total hours per week for infection control activities other than surveillance: __________ Continued >>
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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 40 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 57.103 (Front) Rev 3, v6.4
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