Form 57.503 Denominator for Outpatient Dialysis

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Denominators for Outpatient Dialysis

Census Form – completed once per month

Complete this form as indicated by the Dialysis Event Protocol

Instructions for this form are available at: http://www.cdc.gov/nhsn/forms/instr/57_119.pdf

*required for saving			Page 1 of 1
Reporting to “Outpatient Hemodialysis Clinic” Location: Record the number of patients who received maintenance hemodialysis at your center on the first two working days of the month, including transient patients. A patient must be physically present for in-center maintenance hemodialysis on one of these days to be counted on this form (exclude patients who are hospitalized). Record each patient only once. If a patient has more than one vascular access, record the access type with highest risk for infection.
Facility ID #:
*Location Code:		*Month:		*Year:
*Vascular Access Type		*Number of Maintenance 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)
Custom Fields:
Label	______________	______________	______________			______________	______________
Data	______________	______________	______________			______________	______________
Comments:
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 5, v8.0