57.119 Denominators for Outpatient Dialysis

OMB No. 0920-0666

Exp. Date: 05-31-2014

www.cdc.gov/nhsn

Denominators for Outpatient Dialysis

Census Form – completed once per month

Page 1 of 1
*required for saving
Record the number of chronic hemodialysis patients who received hemodialysis at your center on the first two working days of the month. Count each patient only once. If a patient has both an implanted access (graft or fistula) and a catheter, count this patient as having the catheter.
Facility ID #:
*Location Code:		*Month:		*Year:
*Vascular Access Type		*Number of Chronic Hemodialysis Patients
Fistula					Number of these Fistula Patients who undergo Buttonhole Cannulation
Graft
Tunneled central line
Nontunneled central line
Other access device (e.g., hybrid access)
*Total patients (sum of all patients listed above)
Optional Fields:
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 6 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 57.119 Rev 3, v6.6