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OMB No. 0920-0666

Exp. Date: xx-xx-xxxx
Denominators for Intensive Care Unit (ICU)/
Other locations (not NICU or SCA)
* required for saving

Facility ID:
Date

*Location Code:

*Month:

*Number of patients

**Number of patients
with 1 or more
central lines

Patient-days

Central-line days

*Year:

**Number of patients
with a
urinary catheter

**Number of patients
on a
ventilator

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
Urinary catheter-days

Ventilator-days

** Conditionally required according to the events indicated in Plan.

Label

__________

__________

__________

__________

__________

Data

__________

__________

__________

__________

__________

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 5 hours 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 57.118, v6.4