6_HPS_toi

6_HPS_toi.pdf

The National Healthcare Safety Network (NHSN)

6_HPS_toi

OMB: 0920-0666

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0920-0666 can be found here:

2024-08-26 - No material or nonsubstantive change to a currently approved collection
2024-02-28 - No material or nonsubstantive change to a currently approved collection

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Tables of Instructions
TABLE

CDC
FORM

57.203

Instructions for completion of the Healthcare Personnel
Safety Monthly Reporting Plan form

57.204

Instructions for completion of the Healthcare Worker
Demographic Data form

57.205

Instructions for completion of the Exposures to Blood/Body
Fluids form

57.206

Instructions for completion of the Healthcare Worker
Prophylaxis/Treatment – BBF Postexposure Prophylaxis
form

57.207

Instructions for completion of the Follow-up Laboratory
Testing form

57.211

Instructions for completion of the Pre-season Survey on
Influenza Vaccination Programs for Healthcare
Personnel form

57.209

Instructions for completion of the Healthcare Worker
Influenza Vaccination form

57.210

Instructions for completion of the Healthcare Worker
Prophylaxis/Treatment – Influenza form

57.212

Instructions for completion of the Post-season Survey on
Influenza Vaccination Programs for Healthcare
Personnel form

57.200

Instructions for completion of the Healthcare Personnel
Safety Component Facility Survey form

Last Updated August 26, 2009

TITLE

PAGE

5-1

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 1. Instructions for Completion of the Healthcare Personnel Safety
Monthly Reporting Plan Form (CDC 57.203)
This form collects data on which modules and which months (if any) the facilities intend to participate in
NHSN Healthcare Personnel Safety (HPS) Component. This form should be completed for every month
that the facility will participate in the HPS component.
Data Field

Instructions for Data Collection
Facility ID #
Required. The NHSN-assigned facility ID will be autoentered by the application.
Month/Year
Required. Enter the month and year for the surveillance
plan being recorded.
No NHSN Healthcare Personnel Safety
Conditionally required. Check this box if you do not plan
Modules Followed this Month
to follow any of the NHSN Healthcare Personnel Safety
Modules during the month and year selected.
Healthcare Personnel Exposure Modules
Conditionally required. Check this box if you plan to
Blood/Body Fluid Exposure Only
follow blood/body fluid exposures only, without
following exposure management during the month and
year selected.
Conditionally required. Check this box if you plan to
Blood/Body Fluid Exposure with Exposure
follow blood/body fluid exposure with exposure
Management
management during the month and year selected.
Conditionally
required. Check this box if you plan to
Influenza Exposure Management
follow influenza exposure management (i.e., antiviral
chemoprophylaxis and/or treatment) only, without
following influenza vaccination.
Healthcare Personnel Vaccination Module
Conditionally required. Check this box if you plan to
Influenza Vaccination with Exposure
follow influenza vaccination (either seasonal and/or nonManagement/Treatment
seasonal vaccine) with exposure management (i.e.,
antiviral chemoprophylaxis and/or treatment) during the
month and year selected.

Last Updated August 26, 2009

5-2

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 2. Instructions for Completion of the Healthcare Worker Demographic
Data Form (CDC 57.204)
This form must be completed for all HCP who have information recorded in HPS component of NHSN
(e.g., exposure to blood or body fluid or influenza vaccination.) Alternatively, data for all or selected
personnel can be imported from the facility’s personnel database at facility enrollment.

Data Field
Facility ID #
HCW ID #
Social Security #
Secondary ID #
HCW Name:
Last, First, Middle
Street Address
City
State
Zip Code
Home Phone
E-mail Address
Gender
Date of birth
Born in the U.S.?
Ethnicity
Race
Work Phone
Start Date
Work Status
Type of Employment

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered by the application.
Required. Enter the healthcare worker’s (HCW) alphanumeric identification
number. This identifier is unique to the healthcare facility.
Optional. Enter the HCW’s Social Security Number.
Optional. Enter the HCW’s secondary ID number. This could be the employee’s
medical record # or some other unique identifier.
Optional. Enter demographic information for the HCW.

Required. Indicate the gender of the HCW by checking F (Female) or M (Male).
Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy.
Optional. Select Yes, No, or Unknown.
Optional. Select one ethnicity of the HCW.
Optional. Select the race of the HCW. Check all that apply.
Optional. Enter the work phone number of the HCW.
Required. Enter the date the HCW began employment or affiliation with the facility
(use format: mm/dd/yyyy).
Required. Select Active, Inactive, or No longer affiliated.
Required. Select from Full-time, Part-time, Contract, Volunteer, Other (please
specify).

Last Updated August 26, 2009

5-3

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
Work Location

Department
Supervisor
Occupation
Title

Clinical specialty
Performs direct
patient care
Custom Fields

Comments

Instructions for Data Collection
Required. Select the code that best describes the HCW’s current permanent work
location. This refers to physical work location rather than to department
assignment. For example, a radiology technician who spends most of his/her time
performing portable x-rays throughout the facility works at multiple locations. In
general, most interns/residents are not considered to work at a single location
because they rotate every month or every few months. For HCP who do not work
at least 75% of the time at a single location, the work location code for ‘float’
should be entered. Location codes must be customized to the facility and set up
prior to entering HCW records. The work location must be mapped to a CDC
Location
(http://www.cdc.gov/nhsn/PDFs/pscManual/15LocationsDescriptions_current.pdf).
Optional. Enter the department in which the HCW works (facility defined).
Optional. Enter the name of the HCW’s supervisor (facility defined).
Required. Select the occupation code that most appropriately describes the HCW’s
job. These must be customized to the facility and set up prior to entering HCW
records. The occupation must be mapped to a CDC Occupation Code.
Conditionally required. Required only for HCP designated as Influenza
Vaccinators if the facility intends on using NHSN to fulfill federal recordkeeping
requirements for administration of vaccine covered by the Vaccine Injury
Compensation Program. Enter the HCW’s job title.
Conditionally required. If Occupation is physician, fellow or intern/resident, select
the appropriate clinical specialty.
Conditionally required. Required only when the HCW has influenza vaccination
and/or influenza chemoprophylaxis/treatment records. Select Y (Yes) if the HCW
provides direct patient care (i.e., hands on, face-to-face contact with patients for the
purpose of diagnosis, treatment and monitoring); otherwise select N (No).
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that
may be customized for local use. NOTE: Each Custom Field must be set up in the
Facility/Custom Options section of the application before the field can be selected
for use.
Optional. Enter any information about the HCW. This information cannot be
analyzed.

Last Updated August 26, 2009

5-4

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 3. Instructions for Completion of the Exposures to Blood/Body Fluids
Form (CDC 57.205)
Information for all blood/body fluid exposures should be recorded using this form. The variables to be
entered depend upon whether the facility selects the exposure event only reporting or exposure reporting
and management.
♦

Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).

Data Field
Facility ID #
Exposure Event #
HCW ID
♦

HCW Name:
Last, First, Middle
♦
Gender

Instructions for Data Collection
The NHSN-assigned facility ID will be autoentered by the application.
The exposure event number will be autogenerated by the application.
Enter the HCW’s alphanumeric identification
number. This identifier is unique to the
healthcare facility.
Enter the HCW’s name.

Indicate the gender of the HCW by checking F
(Female) or M (Male).
♦
Date of Birth
Enter the date of birth of the HCW using the
format: mm/dd/yyyy.
♦
Work Location
Required. Select the code that best describes the
HCW’s current permanent work location. This
refers to physical work location rather than to
department assignment. Location codes are
customized to the facility and set up prior to
entering HCW records. See Table 2 for more
details.
♦
Occupation
Required. Select the occupation code that most
appropriately describes the HCW’s job.
Occupation codes are customized to the facility
and set up prior to entering HCW records. See
Table 2 for more details.
Clinical Specialty
If Occupation is physician, fellow or
intern/resident, enter the appropriate clinical
specialty. The list of clinical specialties can be
found on Form CDC 57.204.
Exposure Type
The default setting is auto-entered by the
application as Blood/Body Fluids.
Section I – General Exposure Information
1. Did the exposure
Choose Y (Yes) or N (No).
occur at this facility

Last Updated August 26, 2009

5-5

Exposure
Event Only
Required

Exposure Event
and Exposure
Management
Required

Required

Optional

Required

Conditionally
required

Required

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
1a. If No, specify the
name of facility in
which exposure
occurred
2. Date of exposure
3. Time of exposure
4. Number of hours
on duty
5. Is exposed person
a temp/agency
employee?
6. Location where
exposure occurred
7. Type of Exposure
7a. Percutaneous:
Did the exposure
involve a clean,
unused needle or
sharp object?

7b. Mucous
membrane

Exposure
Event Only
Conditionally
required

Exposure Event
and Exposure
Management
Conditionally
required

Enter date of exposure in mm/dd/yyyy format.
Enter the time the exposure occurred and
whether it was AM or PM.
Enter the number of hours the HCW had been
on duty when the exposure occurred.
Choose Y (Yes) or N (No).

Required
Required

Optional

Choose the appropriate code for the physical
location where the event took place. (This is
customized to the facility).
Check the appropriate exposure type. Check all
that apply.
If Type of Exposure was Percutaneous, then
check this item.

Required

Conditionally
required

If percutaneous is checked, then select Yes or
No to indicate whether the exposure involved a
clean, unused needle or sharp object. If the
incident involved a clean, unused needle or
sharp object you may not need to report this as
an exposure (see your protocol for more
information). If not, check No and complete Q8,
Q9 and Section II. If following the protocol for
exposure management also complete Sections
V-XI.
If Type of Exposure was Mucous Membrane,
then check this item and complete Q8, Q9 and
Section III. If following the protocol for
exposure management also complete Sections
V-XI.

Conditionally
required

Instructions for Data Collection
If the exposure did not occur at the reporting
facility, enter the name of the facility where the
event occurred.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
7c. Skin:
Was skin intact?

7d. Bite

8. Type of
fluid/tissue involved
in exposure

9. Body site of
exposure

Exposure
Event Only
Conditionally
required

Exposure Event
and Exposure
Management
Conditionally
required

If Skin is checked, then indicate Y (Yes), N
(No) or (U) Unknown for whether the skin
remained intact during the exposure. If the
answer is No, complete Q8, Q9 and Section III.
If following the protocol for exposure
management also complete Sections V-XI.
If Type of Exposure was Bite, then check this
item and complete Q9 and Section IV. If
following the protocol for exposure
management also complete Sections V-XI.
Select the Type of fluid/tissue from the list.

Conditionally
required

Required

If Solutions or Body fluids are checked, indicate
whether visibly bloody or not visibly bloody.
For Body Fluids, indicate the primary body
fluid type implicated in the exposure from the
list.

Conditionally
required

If Other is selected for either the Type of
Fluid/Tissue involved in the exposure or the
Body Fluid Type, please specify the type.
(Make sure it is not a body fluid that is already
listed in the box on the right side of the form).
Check body site of exposure from the list.
Check all sites that were exposed.

Conditionally
required

Required

Conditionally
required

Required

Conditionally
required

Instructions for Data Collection
If Type of Exposure was Skin, then check this
item.

If the Body site of exposure was (Other), please
specify the site.
Section II – Percutaneous Injury
1. Was the needle or Choose Y (Yes) or N (No).
sharp object visibly
contaminated with
blood prior to
exposure?
2. Depth of the
Indicate the depth of the injury from the needle
injury (check one)
or sharp object using the list provided.
Exposures that are not obviously superficial
(e.g., scratch) or deep (e.g., “muscle contracted”
or “touched bone”), should be classified as
moderate.

Last Updated August 26, 2009

5-7

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
3. What needle or
sharp object caused
the injury?

Exposure
Event Only
Conditionally
required

Exposure Event
and Exposure
Management
Conditionally
required

Conditionally
required

If Other known device is selected, please
specify.
Enter the brand name and model of the device
used. If the brand and model are unknown,
generic device descriptors can be entered.
Choose Y (Yes) or N (No).
If Yes, answer 5a and 5b. If No, skip to Q6.

Conditionally
required
Conditionally
required

Conditionally
required

If above is Y (Yes), choose one item from the
list of safety devices.

Conditionally
required

Choose the timing of the injury event with
relation to the use of the safety device. Check
one item from the list provided.

Conditionally
required

Instructions for Data Collection
Select one of the following categories: Device,
Non-Device Sharp Object, or Unknown Sharp
Object. If you select Device in the application
you will be provided with a Device button that
will take you to a screen to enter manufacturer,
model, etc. Once a device has been entered you
will be able to select it from the drop down list.
If a Non-Device Sharp is selected, please
describe the item or object.
Within Devices, there are six categories:
Hollow-bore needles, Suture needles, Other
solid sharps, Glass, Plastic, Non-sharp safety
devices, and Other devices.

4. Manufacturer and
model
5. Did the needle or
other sharp object
involved in the
injury have a safety
feature?
5a. If Yes, indicate
the type of safety
feature
5b. If the device had
a safety feature,
when did the injury
occur?

Last Updated August 26, 2009

5-8

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
6. When did the
injury occur?
(check one)
Before use of the
item

Instructions for Data Collection
Choose the timing of the injury event from the
list provided.

During use of the
item

Injuries that occurred during the use of the
needle or sharp object. It also includes surgical
or other invasive procedures with many steps.

After use of item,
before disposal

Injuries that occurred while in transit to
disposal, cleaning instrument or recapping.

During or after
disposal

Injuries that occurred during or after the process
of disposal or because of improper disposal of a
needle or other sharp object.

Unknown

Time of injury relative to the use of the device
or object is unknown.
Choose from the lists provided. If Other specify
the purpose in the space provided.

7. For what purpose
or activity was the
sharp device being
used?

8. What was the
activity at the time
of injury?

Exposure
Event Only
Conditionally
required

Exposure Event
and Exposure
Management
Conditionally
required

Conditionally
required

Injuries that occurred prior to intended use and
usually involve clean needles or sharp objects. It
may also include injuries that occurred with a
clean device that passed through bloody gloves.

Select Unknown if injury was a result of contact
with discarded or uncontrolled sharps, or in
circumstances where the intent of device or
object use is unknown or cannot be ascertained.
Choose the activity being performed at the time
of injury involving the sharp object or needle. If
the activity being performed at the time of the
injury was different than the purpose indicated
in Q7, select the activity at the time the actual
injury event took place.
Select one answer.

9. Who was holding
the device at the
time the injury
occurred?
10. What happened
Choose one item from the list.
when the injury
If Other, please record details in the space
occurred?
provided.
Section III – Mucous Membrane and/or Skin Exposure

Last Updated August 26, 2009

5-9

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
1. Estimate the
amount of
blood/body fluid
exposure
2. Activity/event
when exposure
occurred
3. Barriers used by
the worker at the
time of exposure
Section IV – Bite
1. Wound
description
2. Activity/event
when exposure
occurred

Exposure
Event Only
Conditionally
required

Exposure Event
and Exposure
Management
Conditionally
required

Conditionally
required

If Other is selected record details of the activity
or event in the space provided.
Check all that apply.

Conditionally
required
Conditionally
required

If Other is selected, list other barriers in the
space provided.

Conditionally
required

Select the description of the bite wound from
the list provided.
Choose the activity or event when the bite
occurred.

Conditionally
required
Conditionally
required

Instructions for Data Collection
Select the estimated amount of blood or body
fluid involved in the mucous membrane or skin
exposure. Indicate Unknown if unable to
estimate the amount.
Select the activity or event at the time mucous
membrane or skin exposure occurred.

If Other, specify the event in the space
Conditionally Conditionally
provided.
required
required
Sections V – IX are required when following the protocols for Exposure Management
Section V – Source Information
1. Was the source
Choose Y (Yes) if the source of the exposure
Optional
Required
patient known?
(patient) is known. Otherwise, select N (No).
Indicate Y (Yes) if the source patient’s
Optional
Required
2. Was HIV status
serostatus was known at the time of exposure.
known at time of
exposure?
3. Check the test
Use codes: P= positive, N= negative,
Optional
Required
results for the source I=Indeterminate, U=Unknown, R=Refused and
patient:
NT=Not tested.
Hepatitis B
HbsAg
HBeAg
Total anti-HBc
anti-HBs
Hepatitis C
anti-HCV EIA
anti-HCV suppl
PCR-HCV RNA
HIV
HIV EIA, ELISA
Rapid HIV
Confirmatory HIV

Indicate the results of any tests performed prior
to the exposure (as found in the medical record)
or performed immediately after the exposure. If
the source is not known, check U. If the source
refuses to be tested, check R. Not all tests listed
on the form need to be offered after all
exposures.

Last Updated August 26, 2009

5-10

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
Instructions for Data Collection
Section VI – For HIV Infected Source
1. Stage of Disease
Indicate the stage of HIV disease of the source
patient. Use CDC surveillance definitions. For
end stage AIDS and acute HIV illness, use
definitions as defined in the protocol.
Indicate if the source patient is was taking anti2. Is the source
patient taking antiretroviral drugs at the time of the exposure, Y
retroviral drugs?
(Yes), N (No), or U (Unknown).
2a. If Yes, indicate
If the source patient was taking anti-retroviral
drug(s)
drugs at the time of the exposure, list them here.
Drug codes are listed in Chapter 7 and will be in
a drop down list in the application.
If available, indicate the most recent CD4 count
3. Most recent CD4
in mm3 for the source patient.
count

Exposure
Event Only

Exposure Event
and Exposure
Management

Optional

Conditionally
required

Optional

Conditionally
required

Optional

Conditionally
required

Optional

Conditionally
required

Optional

Conditionally
required

Optional

Required

Optional

Required

Optional

Required

Optional

Conditionally
Required

Date

Enter the month and year of the test for the
source patient.
4. Viral Load
If available, indicate the most recent HIV viral
load (# of copies per ml) or Undetectable for the
source patient.
Date
Enter the month and year of the test.
Section VII: Initial Care Given to Healthcare Worker
1. HIV postexposure
prophylaxis
Offered?

Choose Y (Yes), N (No), or U (Unknown) if
antiretroviral drugs were offered to the HCW
following this exposure.

Taken?

Choose Y (Yes), N (No), or U (Unknown) if
antiretroviral drugs were taken by the HCW. If
Yes is selected, complete Post-Exposure
Prophylaxis/Treatment form (CDC form
57.206).
Choose Y (Yes), N (No), or U Unknown) for
whether Hepatitis B immunoglobulin was given.

2. HBIG given?
Date administered

Enter date HBIG prophylaxis pertaining to this
exposure was administered. Use mm/dd/yyyy
format.

Last Updated August 26, 2009

5-11

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
3. Hepatitis B
vaccine given?

Instructions for Data Collection
Choose Y (Yes), N (No), or U. (Unknown) for
whether Hepatitis B vaccine was given.

Enter date of first dose of Hepatitis B vaccine
(mm/dd/yyyy format). This and subsequent
doses to complete the HBV series should be
recorded in the HCW’s file.
4. Is the HCW
Indicate the pregnancy status of HCW. Choose
pregnant?
Y (Yes), N (No), or U (Unknown).
4a. If yes, which
Check 1 (1st trimester), 2 (2nd trimester), or 3
trimester?
(3rd trimester) at the time of exposure. If stage of
pregnancy is unknown, check U.
Section VIII – Baseline Lab Testing
Was baseline testing Choose Y (Yes) or N (No) or U (Unknown).
Baseline lab tests should be performed within 2
performed on the
weeks of exposure date (either before or after).
HCW?
HIV EIA
Enter the dates for each test performed and the
HIV confirmatory
result (Use codes: P= Positive, N= Negative,
HepC anti-HCV EIA
I=Indeterminate, U=Unknown, R=Refused).
Date first dose
administered

Exposure
Event Only
Optional

Exposure Event
and Exposure
Management
Required

Optional

Conditionally
Required

Optional

Conditionally
required
Conditionally
required

Optional

Required

Optional

Conditionally
required

Optional

Required

HepC anti-HCV-supp
HepC PCR HCV RNA
HepB HBsAg
HepB IgM anti-Hbc
HepB Total anti-Hbc
HepB Anti-HBs
ALT
Amylase
Blood glucose
Hematocrit
Hemoglobin
Platelets
Blood cells in urine
WBC
Creatinine
Other

Additional baseline laboratory tests may be
completed to document potential physiologic
changes associated with a blood/body fluid
exposure. Enter the date (in mm/dd/yyyy
format) and result, using the specified units.

Section IX – Follow-up
1. Is it recommended Choose Y (Yes) or N (No).
that the HCW return
for follow-up of this
exposure?

Last Updated August 26, 2009

5-12

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
Instructions for Data Collection
Choose Y (Yes) or N (No).
1a. If Yes, will
follow-up be
performed at this
facility?
Section X – Narrative
Enter the narrative of the HCW’s description of
In the worker’s
how the injury occurred.
words, how did the
injury occur?
Section XI – Prevention
Enter the narrative of the HCW’s assessment of
In the worker’s
how the injury might have been prevented.
words, what could
have prevented the
injury?
Custom Fields
Up to two date fields, two numeric fields, and
10 alphanumeric fields that may be customized
for local use. NOTE: Each Custom Field must
be set up in the Facility/Custom Options section
of the application before the field can be
selected for use.
Comments
Enter any additional information about the
HCW. This information cannot be analyzed.

Last Updated August 26, 2009

5-13

Exposure
Event Only
Optional

Exposure Event
and Exposure
Management
Conditionally
Required

Optional

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 4. Instructions for Completion of the Healthcare Personnel
Postexposure Prophylaxis Form (CDC 57.206)
Use this form if HIV postexposure prophylaxis (PEP) was administered to a healthcare worker following
a blood or body fluid exposure.
♦

Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).

Data Field
Facility ID #
MedAdmin ID#
HCW ID #
♦

HCW Name:
Last, First, Middle
♦
Gender
♦
Date of Birth
Infectious Agent
Exposure Event #

Initial PEP
Time between
exposure and 1st dose
Drug
Drug
Drug
Drug
Date Started
Date Stopped

Reason for Stopping

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered by the application.
Required. Medical administration number. Data will be auto-entered by the
application.
Required. Enter the HCW’s alphanumeric identification number. This identifier is
unique to the healthcare facility.
Optional. Enter the HCW’s name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male).
Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy.
Required. Enter HIV on form. Select HIV in the application.
Required. The Exposure event number will be auto-entered by the system. Use the
Link/Unlink button to find any exposures for the entered HCW, select, and link
the exposure for which PEP is being administered. PEP records cannot be saved
unless they are linked to an exposure. PEP records entered from the Blood and
Body Fluid Exposure Form will automatically be linked to that exposure.
Indication: Prophylaxis
Required. Enter the number of hours between the exposure and when the 1st dose
of PEP was administered.
Required. Enter any drugs prescribed for prophylaxis. See Chapter 7 in the
protocol for a list of individual drug codes.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Required. Enter the date the initial PEP regimen commenced (mm/dd/yyyy
format). The start date will apply to all drugs selected as the initial PEP regimen.
The date started must be on or after the exposure date.
Required. Enter the date the initial PEP regimen was stopped (mm/dd/yyyy
format).
Note: If any drug(s) of a drug regimen are discontinued, the entire regimen is
considered ‘stopped.’ If select drugs in the regimen continue to be used as
prophylaxis (and if other drugs are added) enter them as drugs under a PEP
change with a new start date.
Required. Indicate the primary reason for stopping the initial PEP regimen by
selecting the appropriate choice.

Last Updated August 26, 2009

5-14

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
PEP Change 1
Drug
Drug
Drug
Drug
Date Started
Date Stopped

Reason for Stopping
PEP Change 2
Drug
Drug
Drug
Drug
Date Started
Date Stopped

Reason for Stopping
Adverse Reactions
Signs or symptoms of
adverse reactions to
post-exposure
prophylaxis
Custom Fields

Comments

Instructions for Data Collection
Indication: Prophylaxis
Required. Enter drugs prescribed for a second prophylaxis regimen. Note that the
second PEP regimen may contain drugs that were included in the first regimen.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter the date the second PEP regimen was started using
mm/dd/yyyy format.
Conditionally required. Enter the date the second PEP regimen was stopped using
mm/dd/yyyy format.
Note: If any drug(s) of a drug regimen are discontinued, the regimen is
considered ‘stopped.’ Whatever drugs in the regimen are continued (and if other
drugs are added) will constitute a new regimen and should be entered as such.
Conditionally required. Indicate the primary reason for stopping this PEP regimen
by selecting the appropriate choice.
Indication: Prophylaxis
Conditionally required. Enter drugs prescribed for a third prophylaxis regimen.
Note that the third PEP regimen may contain drugs that were included in previous
regimens.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter any additional drugs prescribed for prophylaxis.
Conditionally required. Enter the date the new PEP regimen was started using
mm/dd/yyyy format.
Conditionally required. Enter the date the new PEP regimen was stopped using
mm/dd/yyyy format.
Note: If any drug(s) of a drug regimen are discontinued, the regimen is
considered ‘stopped.’ Whatever drugs in the regimen are continued (and if other
drugs are added) will constitute a new regimen and should be entered as such.
Conditionally required. Indicate the primary reason for stopping this PEP regimen
by selecting the appropriate choice.
Optional. Indicate any adverse signs/symptoms the HCW experienced while
receiving postexposure prophylaxis. You may select up to six.
If Other is selected, briefly specify details of adverse reaction.
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields
that may be customized for local use. NOTE: Each Custom Field must be set up
in the Facility/Custom Options section of the application before the field can be
selected for use.
Optional. Enter any additional information about the HCW. This information
cannot be analyzed.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 5: Instructions for Completion of Follow-Up Laboratory Testing Form
(CDC 57.207)
This form should be completed for HCP who have additional laboratory testing done as a result of blood
or body fluid exposures. These tests would occur after baseline laboratory testing had been completed.
♦

Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).

Data Field
Facility ID #
Lab #
HCW ID #
♦

HCW Name:
Last, First, Middle
♦
Gender
♦
Date of birth
Exposure Event #

Lab Results
Lab Test

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered by the application.
Required. The lab testing ID number will be auto-generated by the application.
Required. Enter the HCW’s alphanumeric identification number. This identifier is
unique to the healthcare facility.
Optional. Enter the HCW’s name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male).
Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy.
Required. The user is required to link the laboratory follow-up record to a blood and
body fluid exposure record using the Link feature within the application. Once the
exposure is selected and submitted, the form will display the message “Lab is
Linked.” Laboratory records must be linked to an exposure.
Required (At least one laboratory test and date are required). Select lab test from
dropdown menu:
HIV EIA
HIV confirmatory
HepC anti-HCV EIA
HepC anti-HCV-supp
HepC PCR HCV RNA
HepB HBsAg
HepB IgM anti-Hbc
HepB Total anti-Hbc
HepB Anti-HBs

Date
Result
Custom Fields

Comments

ALT
Amylase
Blood glucose
Hematocrit
Hemoglobin
Platelets
Blood cells in urine
WBC
Creatinine
Other

Required. Indicate date of test using mm/dd/yyyy format.
Conditionally required. Select one of the result codes:
Use codes: P= positive, N= negative, I=Indeterminate, U=Unknown, R=Refused)
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that
may be customized for local use. NOTE: Each Custom Field must be set up in the
Facility/Custom Options section of the application before the field can be selected
for use.
Optional. Enter any additional information about the HCW. This information cannot
be analyzed.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 6. Instructions for Completion of the Pre-season Survey on Influenza
Vaccination Programs for Healthcare Personnel Form (CDC 57.211)
This form is used to report plans for the facility’s influenza vaccination campaign. In addition,
denominator data regarding the target vaccination population (i.e., number of FTEs, PTEs, contractors,
volunteers, others) are collected. This form should be completed at the beginning of the vaccination
season.
Data Field
Facility ID #
Date Entered
For Season

Vaccination campaign for: Seasonal influenza
subtype, Non-seasonal influenza subtype, Both

1. Which personnel groups do you plan to
include in your annual influenza vaccination
program?
2. Which of the following types of employees
do you plan to include in your annual influenza
vaccination program? (Check all that apply)

3. At what cost will you provide influenza
vaccine to your healthcare workers?
4. Will influenza vaccination be available
during all work shifts (including nights and
weekends)?
5. Which of the following methods do you plan
to use this influenza season to deliver vaccine to
your healthcare workers?

Last Updated August 26, 2009

5-17

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be autoentered by the application.
Required. The month and year that the pre-season
survey was filled out.
Required. Years of the vaccination season for which
survey was completed entered in the format: yyyy –
yyyy. Vaccination season is 9/1 of the current year to
8/31 of the following year.
Required. Select the influenza subtype for the campaign
described in this survey. Select “Both” if your
vaccination campaign and target populations are the
same for both influenza subtypes. If your campaign
and/or target populations will be different for seasonal
and non-seasonal influenza subtypes, complete a
separate pre-season survey for each subtype.
Required. Check the personnel group you plan to
include.
Required. Check each type of employee you plan to
include in your influenza vaccination program.
For each type of employee you checked, enter the
estimated number of employees. This should be the
estimated number of employees in each category who
you intend on vaccinating during the season.
Required. Check one cost category that best describes
your plan for providing influenza vaccinations for the
majority of the personnel group specified above.
Required. Check Yes or No.
Required. Check all methods that you plan to use to
deliver influenza vaccination this season.

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
6. Which of the following strategies do you plan
to use to promote/enhance healthcare worker
influenza vaccination at your facility?
7. Do you plan to conduct any formal
educational programs on influenza and
influenza vaccination for your healthcare
workers?
8. If you plan to conduct formal educational
programs on influenza and influenza
vaccination, will your healthcare workers be
required to attend?
9. Will you require healthcare workers who
receive off-site influenza vaccination to provide
documentation of their vaccination status?
10. Will you required signed declination
statements from healthcare workers who refuse
influenza vaccination?
11. Vaccine information statement edition date

Comments

Last Updated August 26, 2009

5-18

Instructions for Data Collection
Required. Check all strategies you plan to use in order to
promote or enhance influenza vaccination at your
facility.
Required. Check Yes or No.

Conditionally required if you plan on conducting formal
education programs (i.e., you checked Yes for Question
7). Check Yes or No.
Required. Check Yes or No.
Required. Check Yes or No.
Required. Enter the edition date for the official vaccine
information statement (VIS) for the seasonal and nonseasonal influenza vaccines that you will be distributing
to your employees at ONSITE vaccinations. VISs can be
found on the CDC website at
http://www.cdc.gov/vaccines/pubs/vis/. Enter the VIS
edition date of the primary type of vaccine (e.g.,
inactivated) that your facility will be using. If the preseason survey reflects “Both” seasonal and non-seasonal
influenza vaccines, then enter the edition dates for both
vaccines. This date will be used to auto-fill the HCW
vaccination records that are entered for the applicable
edition dates. You can edit the date on the vaccination
record to reflect a secondary type of vaccine (e.g., live
attenuated). The edition dates are required if you plan to
use NHSN to satisfy federal record-keeping
requirements for the administration of vaccine covered
by the Vaccine Injury Compensation Program.
Optional. Enter any additional information about the
HCW. This information cannot be analyzed.

NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 7. Instructions for Completion of the Healthcare Worker Influenza
Vaccination Form (CDC 57.209)
This form is used to collect information on whether an individual HCW received or declined the influenza
vaccine, and the details of that vaccination. A separate form must be filled out for each vaccination dose.
For example, if a HCW received 1 dose of seasonal influenza vaccine and 2 doses of non-seasonal
influenza vaccine, there should be three separate vaccination forms. A pre-season survey (CDC 57.211),
an annual facility survey (CDC 57.200), and a monthly reporting plan for the month of vaccination (CDC
57.203) must be completed before vaccination records can be entered in NHSN.
♦

Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).
+Data elements that are carried forward from one vaccination record to the next during batch data entry.

Data Field
+Facility ID #
Vaccination ID #

HCW ID #
♦

HCW Name:
Last, First, Middle
♦
Gender
♦
Date of birth
♦
Work Location

♦

Occupation

♦

Clinical Specialty

♦

Performs direct patient
care

+Type of vaccination
+Influenza subtype
(years)

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered by the
application.
Required. The vaccination ID number is a unique NSHN locator number for
that specific vaccination record that will be auto-generated by the
application.
Required. Enter the HCW’s alphanumeric identification number. This identifier
is unique to the healthcare facility.
Optional. Enter the HCW’s name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male).
Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy.
Required. Select the code that best describes the HCW’s current permanent work
location. This refers to physical work location rather than to department
assignment. Location codes are customized to the facility and set up prior to
entering HCW records. See Table 2 for more details.
Required. Select the occupation code that most appropriately describes the
HCW’s job. Occupation codes are customized to the facility and set up prior to
entering HCW records. See Table 2 for more details.
Conditionally required. If Occupation is physician, fellow or intern/resident,
enter the appropriate clinical specialty. The list of clinical specialties can be
found on Form CDC 57.204.
Required. Select Yes if the HCW provides direct patient care (i.e., hands on, face
to face contact with patients for the purpose of diagnosis, treatment and
monitoring); otherwise select No.
Required. Influenza is pre-filled on form and auto-entered by the application.
Required. Select seasonal vaccine or non-seasonal (e.g., 2009 H1N1) vaccine.
For either subtype specify the vaccination years during which this vaccination
date (or the date the vaccination was offered) falls. For NHSN purposes, the
vaccination year is 9/1 of the first year to 8/31 of the following year.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
+Do you plan to use this
information to satisfy
federal record-keeping
requirements for the
administration of vaccine
covered by the Vaccine
Injury Compensation
Program?

Instructions for Data Collection
Required. Check Yes or No. If you select Yes, information on the person
administering the vaccine (i.e., the vaccinator) will be required per federal
record-keeping requirements.

+Vaccine administered

Required. Select the appropriate location of vaccine administration (ONSITE or
OFFSITE). If the HCW declined vaccination, indicate primary reason for
declination. Check “Declined due to medical contraindications” if the HCW has
severe allergy to chicken eggs or other vaccine components or has developed
Guillain-Barre´ syndrome within 6 weeks of getting an influenza vaccine. Select
“Declined due to personal reasons” for all other reasons.

Reasons for declining
due to personal reasons:
+Date of vaccination

Conditionally required. If the HCW declined influenza vaccination for personal
reasons, select the reason(s) for declining.
Conditionally required – Date is required if the vaccination was administered
ONSITE or OFFSITE. Enter the vaccination date using mm/dd/yyyy format. If
the exact date of an OFFSITE vaccination is unknown, use the 15th of the month:
mm/15/yyyy. The HCW cannot receive two doses of the same vaccine on the
same day.
Conditionally required if vaccine was administered ONSITE. Select the product
used in this vaccination. For a NON-SEASONAL vaccine, please select “Other”
and specify the name of the NON-SEASONAL vaccine.

+Product

+Manufacturer

Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. Manufacturer will
be auto-entered by the application based on the product that is selected. For a
NON-SEASONAL vaccine, specify the manufacturer of the vaccine.

+Lot number

Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. Enter the lot
number of the vaccine administered to the HCW.

+Type of influenza
vaccine

Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. Type of influenza
vaccine will be auto-entered by the application based on the product that is
selected. Select either “Live attenuated” or “Inactivated vaccine.”

+Route of
administration

Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. Route of
administration will be auto-entered by the application based on the product that
is selected. In rare instances, where some products may be administered
subcutaneously (SUBQ), you can manually change the route of administration.
Optional if vaccine was administered OFFSITE.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
Adverse reaction to the
vaccine

Instructions for Data Collection
Conditionally required if vaccine was administered ONSITE. Select Yes if the
HCW had an adverse reaction attributable to the vaccine; otherwise select No.
Select “Don’t know” if it is unknown whether the HCW experienced an adverse
reaction.
Optional if vaccine was administered OFFSITE.

If Yes, check all that
apply

+Which vaccine
information statement,
including edition date,
was provided to the
vaccinee?
+Edition date [of
Vaccine Information
Statement (VIS)]

Vaccinator ID

♦

Name, Last
First
Middle
Work address, City,
State, Zip code
♦

Title

Custom Fields

Comments

Conditionally required if vaccine was administered ONSITE. Select all adverse
reactions that apply. If Other is checked, please specify the reaction the HCW
experienced.
Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. Vaccine
information statement type will be auto-entered by the application based on the
product that is selected.
Optional if vaccine was administered OFFSITE.
Conditionally required if vaccine was administered ONSITE. The edition date of
the primary VIS will be auto-entered by the application based on the answer to
Question 11 on the Pre-season Survey. If another vaccine is administered, you
can edit the edition date to reflect the secondary VIS.
Optional if vaccine was administered OFFSITE.
Conditionally required for ONSITE vaccinations if NHSN will be used to satisfy
federal record-keeping requirements for the administration of vaccine (You
checked Yes to the Federal record-keeping question). Enter the HCW ID # of the
person administering the vaccine.
Conditionally required for ONSITE vaccinations if NHSN will be used to satisfy
federal record-keeping requirements for the administration of vaccine. Enter the
vaccinator’s first and last names. Middle name is optional.
Conditionally required for ONSITE vaccinations. The vaccinator’s work address
will be auto-entered by the application from data entered on the Facility form.
Conditionally required for ONSITE vaccinations if NHSN will be used to satisfy
federal record-keeping requirements for the administration of vaccine. Enter the
vaccinator’s job title which does not have to match a CDC occupation Code.
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields
that may be customized for local use. NOTE: Each Custom Field must be set up
in the Facility/Custom Options section of the application before the field can be
selected for use.
Optional. Enter any additional information about the HCW. This information
cannot be analyzed.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 8. Instructions for Completion of the Healthcare Worker Influenza
Antiviral Medication Administration Form (CDC 57.210)
This form should be completed when an HCW receives antiviral medications as influenza treatment or as
chemoprophylaxis against influenza infection. It is used to collect information on which antiviral
medications were administered, when, and what (if any) adverse reactions were experienced by the HCW.
♦

Demographic data auto-entered by application if part of an existing HCW Demographic Data record (CDC 57.204).

Data Field
Facility ID #
Med Admin ID #
HCW ID #
♦

HCW Name:
Last, First, Middle
♦
Gender
♦
Date of Birth
♦
Work Location

♦

Occupation

♦

Clinical Specialty

♦

Performs direct
patient care

Infectious agent
For season
#
Indication
Influenza subtype
Antiviral
medication
Start date

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered by the application.
Required. The medication administration ID number will be auto-generated by the
application.
Required. Enter the HCW’s alphanumeric identification number. This identifier is
unique to the healthcare facility.
Optional. Enter the HCW’s name.
Required. Indicate the gender of the HCW by checking F (Female) or M (Male).
Required. Enter the date of birth of the HCW using the format: mm/dd/yyyy.
Required. Select the code that best describes the HCW’s current permanent work
location. This refers to physical work location rather than to department assignment.
Location codes are customized to the facility and set up prior to entering HCW
records. See Table 2 for more details.
Required. Select the occupation code that most appropriately describes the HCW’s
job. Occupation codes are customized to the facility and set up prior to entering
HCW records. See Table 2 for more details.
Conditionally required. If Occupation is physician, fellow or intern/resident, enter the
appropriate clinical specialty. The list of clinical specialties can be found on Form
CDC 57.204.
Required. Select Yes if the HCW provides direct patient care (i.e., hands on, face-toface contact with patients for the purpose of diagnosis, treatment and monitoring);
otherwise select No.
Required. Auto-filled on hard copy form. Select Influenza in application.
Required. Select the vaccination season. Specify the year(s) during which this
chemoprophylaxis or treatment date falls. For NHSN purposes, the vaccination
“season” is 9/1 of the first year to 8/31 of the second year.
Required. Indicate up to 10 antiviral medications given using sequential numbers
starting with 1.
Required. Select Prophylaxis or Treatment as appropriate.
Required. Select the influenza subtype for which the HCW is receiving antiviral
medications (for post-exposure chemoprophylaxis or for treatment). Select Unknown,
if you do not know the specific subtype necessitating antiviral medication use.
Required. Enter the code of the antiviral medication that was administered to the
HCW using the codes listed at the bottom of the form.
Required. Enter the start date of the antiviral using mm/dd/yyyy format.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
Stop date
Adverse reactions?
Adverse reactions
to antiviral
medication
#1…#10
Custom Fields

Comments

Instructions for Data Collection
Conditionally required. Enter the stop date of the antiviral using mm/dd/yyyy format.
Required. Check Yes if the HCW had a severe adverse reaction attributable to the
influenza antiviral medication; otherwise check No. If it is unknown whether or not
the HCW experienced any adverse reactions, check Don’t Know.
Conditionally required. If the HCW had a severe adverse reaction, check all reactions
that apply for each medication administered. Please correlate the antiviral medication
# with the antiviral medication on page 1. If an adverse reaction is not listed, check
Other and specify the adverse reaction in the space provided. All Other adverse
reactions should be included if the reactions were severe enough to affect daily
activities and/or resulted in the discontinuation of the antiviral medication.
Optional. Up to two date fields, two numeric fields, and 10 alphanumeric fields that
may be customized for local use. NOTE: Each Custom Field must be set up in the
Facility/Custom Options section of the application before the field can be selected for
use.
Optional. Enter any additional information about the HCW. This information cannot
be analyzed.

Last Updated August 26, 2009

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 9. Instructions for Completion of the Post-season Survey on Influenza
Vaccination Programs for Healthcare Personnel Form (CDC 57.212)
This form is used to report the facility’s implemented influenza vaccination campaign. This survey will

capture any changes that occurred to the facilities’ vaccination strategy and/or target vaccination
population during the vaccination season. This form should be completed at the conclusion of the
vaccination season.
Data Field
Facility ID #
Date Entered
For Season

Vaccination campaign for: Seasonal
influenza subtype, Non-seasonal influenza
subtype, Both.

1. Which personnel groups did you
include in your annual influenza
vaccination program this past season?
2. Which of the following types of
employees did you include in your annual
influenza vaccination program this past
season? (Check all that apply)
3. At what cost did you provide influenza
vaccine to your healthcare workers?
4. Did you provide influenza vaccination
during all work shifts (including nights
and weekends)?
5. Which of the following methods did
you use during influenza season to deliver
vaccine to your healthcare workers?

Last Updated August 26, 2009

Instructions for Data Collection
Required. The NHSN-assigned facility ID will be auto-entered
by the application.
Required. The month and year that the post-season survey was
filled out.
Required. Years of the vaccination season for which the
survey was completed, entered in the format: yyyy – yyyy.
Vaccination season is 9/1 of the current year to 8/31 of the
following year.
Required. Select the influenza subtype for the campaign
described in this survey. If your campaign and target
populations were the same for both influenza vaccination
subtypes and you completed a single pre-season survey, select
Both. If your campaign and target populations were different
for seasonal vs. non-seasonal subtypes, you should complete a
separate post-season survey for each.
Required. Check the personnel group(s) you included in your
campaign or program.
Required. Check each type of employee you included in your
influenza vaccination program. Data for each type of
employee that you checked for the pre-season survey will be
auto-entered into the post-season survey. If your target
vaccination population changed over the course of the season,
you can edit the number.
Required. Check one cost category that best describes how
you provided influenza vaccinations to the majority of the
personnel group specified above.
Required. Choose Yes or No.
Required. Check all methods that you used to deliver
influenza vaccination this season.

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Data Field
6. Which of the following strategies did
you use to promote/enhance healthcare
worker influenza vaccination at your
facility?
7. Did you conduct any formal
educational programs on influenza and
influenza vaccination for your healthcare
workers?
8. If you conducted formal educational
programs on influenza and influenza
vaccination, did you require your
healthcare workers to attend?
9. Did you require healthcare workers
who received off-site influenza
vaccination to provide documentation of
their vaccination status?
10. Did you require signed declination
statements from healthcare workers who
refused influenza vaccination?

Last Updated August 26, 2009

Instructions for Data Collection
Required. Check all strategies you used in order to promote or
enhance influenza vaccination at your facility.
Required. Indicate if you conducted formal educational
programs on influenza and influenza vaccination for your
HCP.
Conditionally required if you conducted formal education
programs (you checked Yes for Question 7). Check Yes or
No.
Required. Check Yes or No.

Required. Check Yes or No.

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

Table 10. Instructions for Completion of Healthcare Personnel Safety
Component Facility Survey Form (CDC 57.200)
This form must be completed once a year by any facility using the Healthcare Personnel Safety
Component.
Data Field
Tracking #
Facility ID #
Survey year
Total beds set up and staffed
Patient admissions
Inpatient days
Outpatient encounters
Number of hours worked by
all employees

Number of HCWs

Number of FTEs

Last Updated August 26, 2009

Instructions for Data Collection/Entry
Required. The NHSN-assigned Tracking # will be auto-entered by the
application.
Required. The NHSN-assigned facility ID will be auto-entered by the
application.
Required. Enter the year of the survey using the format: yyyy.
Required. Enter the number of all active beds across specialties and
intensive care units.
Required. Enter the number of patients, excluding newborns, admitted for
inpatient service.
Required. Enter the number of adult and pediatric days of care, excluding
newborn days of care, rendered during a specified reporting period.
Required. Enter the number of visits by patients who are not admitted as
inpatients to the hospital while receiving medical, dental, or other services.
Optional. Number of hours worked is available from OSHA300 reporting
logs. The value can also be calculated by identifying the number of full
time employees working in your facility within a year, multiply by the
number of work hours for one full time employee in a year (typically
ranges from 2000-2100 hours per year). Add in overtime hours and total
hours worked by part-time, temporary, and contracted staff.
Required. HCWs are all persons who work in the hospital. Similar to the
AHA survey, calculate the number of attending physicians by including
only those who are active or associate staff. Do not include courtesy,
consulting, honorary, provisional, or other attending physicians in this
number. If you cannot determine the exact number for a particular category,
please estimate it. If the facility does not have any HCP in a specific
occupation, the user may enter 0. This is the denominator when used to
calculate rates of particular exposure events per HCW.
Required. A subset of total number of HCP. FTEs are all HCP whose
regularly scheduled workweek is 35 hours or more. To calculate the
number of FTE’s add the number of FTEs to ½ the number of part-time
HCP (e.g., 2 part-time HCP = 1 FTE). If you cannot determine the exact
number for a particular category, please estimate it. If the facility does not
have any FTEs in a specific occupation, the user may enter 0. This is the
denominator used to calculate rates of particular exposure events per FTE.

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NHSN Healthcare Personnel Safety Component
Tables of Instructions

REFERENCES
The following CDC/PHS publications provide recommendations for management and follow-up of blood and body
fluid exposures to HBV, HCV, and HIV:
• Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV,
HCV, and HIV and Recommendations for Postexposure Prophylaxis. (MMWR, June 29, 2001 / 50(RR11); 142)
• Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Postexposure Prophylaxis (PEP regimens have been changed). (MMWR, September
30, 2005 / 54(RR09); 1-17)

The following CDC/PHS publication provides recommendations for the immunization of HCP:
• A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the
United States. (MMWR, December 8, 2006 / 55(RR16); 1-25)
• Influenza Vaccination of Health-care Personnel. (MMWR, February 24, 2006 / 55(RR02); 1-16)
• Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). (MMWR, July 29, 2009 / 58(Early Release); 1-52)

Last Updated August 26, 2009

5-27

File Type	application/pdf
File Title	The National Healthcare Safety
Author	CDC
File Modified	2009-08-26
File Created	2009-08-26