Form Approved
OMB No. 0920-xxxx
Exp. Date: xx/xx/20xx
www.cdc.gov/nhsn
State Health Department Validation Record
Page 1 of 6 |
*required **conditionally required |
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Facility Validation Overview |
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*Facility ID: |
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*Facility Type: |
□ Acute care hospital |
□ Long term acute care hospital (LTAC/LTCH) |
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□ Oncology hospital |
□ Inpatient rehabilitation facility (IRF) |
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*Sampling version: |
□ CDC Version 1 (Targeted Sampling) |
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*Data for year: |
□ 2013 |
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*HAI validated at this facility, and reason: |
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□ CLABSI (ICU, includes NICUs if applicable) |
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□ CAUTI (ICU, excludes NICUs) |
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□ COLO (DI/OS SSI) |
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□ HYST (DI/OS SSI) |
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□ MRSA bacteremia LabID event |
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□ CDI LabID event |
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Reason: |
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□ All facilities are validated |
□ Targeted facility |
□ 5% random sample facility |
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Numerator Validation |
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*Sampling information for numerator audit at this facility |
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Event |
Sampling frame elements |
Sampling Frame (# elements eligible for review for year) |
Total # events from facility reported to NHSN for year (before validation) |
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**ICU (including NICU) CLABSI |
Medical records with positive ICU blood culture(s) |
______ |
______ |
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**ICU (excluding NICU) CAUTI |
Medical records with positive ICU urine culture(s) |
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______ |
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**DI/OSa COLO SSI |
COLO procedures |
______ |
______ |
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**DI/OSa HYST SSI |
HYST procedures |
______ |
______ |
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**MRSA bacteremia labID event |
Inpatientb blood cultures positive for MRSA |
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______ |
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**CDI labID event |
Inpatientb stools toxin-positive for C. difficile, excluding those from “baby locations” |
______ |
______ |
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aDI/OS - deep incisional or organ/space SSI |
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bInpatient includes specimens collected on day of admission from ED or other outpatient location |
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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 15 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 57.600 (Front) v8.1 |
State Health Department Validation Record
Page 2 of 6 |
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Numerator Validation (continued) |
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*Facility audit results, numerators |
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**CLABSI in ICU (including NICU): |
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Facility determination |
Audit-CLABSI Yes |
Audit-CLABSI No |
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Date-matched CLABSI reported |
a. ____ |
b. ____ |
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Date-matched CLABSI NOT reported |
c. ____ |
d. ____ |
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**CAUTI in ICU (excluding NICU): |
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Facility determination |
Audit-CAUTI Yes |
Audit-CAUTI No |
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Date-matched CAUTI reported |
a. ____ |
b. ____ |
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Date-matched CAUTI NOT reported |
c. ____ |
d. ____ |
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**DI/OS COLO SSI: |
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Facility determination |
Audit-DI/OS SSI Yes |
Audit-DI/OS SSI No |
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Date-matched DI/OS SSI reported |
a. ____ |
b. ____ |
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Date-matched DI/OS SSI NOT reported |
c. ____ |
d. ____ |
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**DI/OS HYST SSI: |
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Facility determination |
Audit-DI/OS SSI Yes |
Audit-DI/OS SSI No |
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Date-matched DI/OS SSI reported |
a. ____ |
b. ____ |
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Date-matched DI/OS SSI NOT reported |
c. ____ |
d. ____ |
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**MRSA bacteremia LabID event: |
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Facility determination |
Audit-MRSA bacteremia culture reportable LabID event |
Audit-MRSA bacteremia culture NOT reportable LabID event |
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Date-matched MRSA blood culture reported as LabID event |
a. ____ |
b. ____ |
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Date-matched MRSA blood culture NOT reported as LabID event |
c. ____ |
d. ____ |
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**CDI LabID event: |
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Facility determination |
Audit-CDI test reportable LabID event |
Audit-CDI test NOT reportable LabID event |
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Date-matched CDI test reported as LabID event |
a. ____ |
b. ____ |
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Date-matched CDI test NOT reported as LabID event |
c. ____ |
d. ____ |
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State Health Department Validation Record
Page 3 of 6 |
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Denominator Validation: CLABSI |
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**Which method was used by this facility for ICU CLABSI denominator (patient days and central line days) counting for this year? |
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□ Manual counting |
□ Electronic counting |
□ Both manual and electronic counting |
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**Has this facility completed an internal validation of ICU CLABSI denominator data for this year? |
□ Yes |
□ No |
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Note: Validation of manual denominator data counting requires either:
Validation of electronic denominator data counting requires:
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**If yes, provide the following information for all locations and months validated: |
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Location of validation |
Month of validation |
Validation method |
Count 1 |
Count 2 |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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Note: If Method A is chosen, Count 1 should be “Usual Count” and Count 2 should be “Expert (Referent) Count”; If Method B is chosen, Count 1 should be “Usual Count” and Count 2 should be ”Patient-level (Referent) Count”; If Method C is chosen, Count 1 should be “Manual Count” and Count 2 should be “Electronic Count.” |
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Denominator Validation: CAUTI |
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**Which method was used by this facility for ICU CAUTI denominator (patient days and catheter days) counting for this year? |
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□ Manual counting |
□ Electronic counting |
□ Both manual and electronic counting |
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**Has this facility completed an internal validation of ICU CAUTI denominator data for this year? |
□ Yes |
□ No |
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Note: Validation of manual denominator data counting requires either:
Validation of electronic denominator data counting requires:
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**If yes, provide the following information for all locations and months validated: |
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Location of validation |
Month of validation |
Validation method |
Count 1 |
Count 2 |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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A, B, or C |
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Note: If Method A is chosen, Count 1 should be “Usual Count” and Count 2 should be “Expert (Referent) Count”; If Method B is chosen, Count 1 should be “Usual Count” and Count 2 should be ”Patient-level (Referent) Count”; If Method C is chosen, Count 1 should be “Manual Count” and Count 2 should be “Electronic Count.” |
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State Health Department Validation Record
Page 4 of 6 |
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Denominator Validation: COLO |
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**Document number of COLO procedures from two systems by month: |
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Month |
Number of COLO procedures entered into NHSN by facility before validation |
Number of ICD-9 procedure codes for COLO identified from hospital discharge billing |
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Denominator Validation: HYST |
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**Document number of HYST procedures from two systems by month: |
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Month |
Number of HYST procedures entered into NHSN by facility before validation |
Number of ICD-9 procedure codes for HYST identified from hospital discharge billing |
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Denominator Validation: MRSA bacteremia LabID event & CDI LabID event |
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NHSN inpatient location validation |
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**Do any inpatient locations require mapping or re-mapping within NHSN? |
□ Yes |
□ No |
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**If yes, indicate which locations need to be mapped/re-mapped and recommendations: |
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Location |
Current CDC location code designation |
Current bed count |
Recommended CDC location code designation |
Recommended bed count |
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**How does this facility obtain inpatient admissions data? |
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□ Electronic from billing |
□ Electronic from vendor system |
□ Electronic from ADT |
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□ Other (specify): ____________________________________________ |
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**How does this facility obtain inpatient patient days data? |
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□ Electronic from billing |
□ Electronic from vendor system |
□ Electronic from ADT |
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□ Other (specify): ____________________________________________ |
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State Health Department Validation Record
Page 5 of 6 |
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Denominator Validation: MRSA bacteremia LabID event & CDI LabID event (continued) |
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**Has this facility completed any internal validation of LabID event denominator data counting? |
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□ Yes |
□ No |
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Note: Validation of denominator data counting requires concurrent patient level denominator counting (reference) vs. standard electronic data for three specified location types [one ICU, one LDRP if available, and one or more wards where observation patients are frequently housed] for ≥1 month; validated data should fall within 5% of the reference standard (see validation Guidance and Toolkit Appendix 1). |
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**If yes, provide the following information for all months validated: |
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MRSA bacteremia LabID event |
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Location of validation |
Month of validation |
Admissions |
Patient Days |
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Usual count |
Manual count |
Usual count |
Manual count |
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CDI LabID eventc |
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Location of validation |
Month of validation |
Admissions |
Patient Days |
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Usual count |
Manual count |
Usual count |
Manual count |
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cExcludes ‘baby locations’ |
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Risk Adjustment Variable Validation |
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**ICU mapping (ICU CLABSI [includes NICUs], ICU CAUTI [excludes NICUs]) |
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Number of ICU locations correctly mapped as ICUs in NHSN (includes NICUs): |
_________ |
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Number of locations incorrectly mapped as ICUs (includes NICUs): |
_________ |
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Number of ICUs (includes NICUs) omitted from ICU mapping: |
_________ |
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Number of ICU mapping errors (ICUs vs. non-ICUs): |
_________ |
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**Teaching hospital affiliation (ICU CLABSI, ICU CAUTI, MRSA bacteremia LabID event, CDI LabID event) |
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Facility teaching hospital affiliation reported on 2013 NHSN annual facility survey: |
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□ Non-teaching |
□ Major |
□ Graduate |
□ Undergraduate |
□ N/A (IRF & LTAC) |
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Is facility teaching hospital affiliation correct? |
□ Yes |
□ No |
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**ASA score (COLO, HYST) |
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Number (% of audited) correct for COLO: |
_________ |
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Number (% of audited) correct for HYST: |
_________ |
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State Health Department Validation Record
Page 6 of 6 |
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Risk Adjustment Variable Validation (continued) |
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**Patient age (COLO, HYST) |
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Number (% of audited) correct for COLO: |
_________ |
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Number (% of audited) correct for HYST: |
_________ |
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**Facility bed size (all inpatient locations, including ‘baby locations’) (MRSA bacteremia LabID event, CDI LabID event) |
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Facility bed size reported on 2013 NHSN annual facility survey: |
_________ |
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Validated bed size: |
_________ |
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Custom Fields |
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Label |
Label |
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_________________________ |
____/____/_____ |
_______________________ |
____/____/_____ |
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_________________________ |
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_______________________ |
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_________________________ |
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_______________________ |
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_________________________ |
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_______________________ |
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Comments |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Arnold, Kathryn E. (CDC/OID/NCEZID) |
File Modified | 0000-00-00 |
File Created | 2021-01-28 |