Form 57.100 NHSN Registration Form

1. Personal Information

   *Last Name:___________________ *First Name: ____________________

   Middle Name:_____________________

   *Email address: ______________________________________________

1. Facility Identifier

   *Please select a facility identifier:

1. □ CMS Certification Number (CCN)        □ AHA ID                     □ VA Station Code

   □ CDC Registration ID                 □ None

1. *Selected identifier ID: __________________

1. Facility Administrator Role

   As the NHSN facility administrator, will you have an active role in the collection, entry, and/or analysis of data in NHSN, or provide guidance on the use of protocols for the component(s) in which you are enrolling?

   _____ Yes        _____ No

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	XZD7
Last Modified By	ano3
File Modified	2010-08-16
File Created	2005-08-29