National Healthcare Safety Network (NHSN)
OMB Control No. 0920-0666
Revision Request June 2015
NHSN Forms used for Current or Future CMS Quality Reporting Programs (QRPs) and State Mandates
Form Number |
Form Name |
No. of Respondents |
Mandated for current or future CMS QRP |
Mandated for current or future State Reporting |
57.100 |
NHSN Registration Form |
2,000 |
Yes |
Yes |
57.101 |
Facility Contact Information |
2,000 |
Yes |
Yes |
57.103 |
Patient Safety Component--Annual Hospital Survey |
5,000 |
Yes |
Yes |
57.105 |
Group Contact Information |
1,000 |
No |
Yes |
57.106 |
Patient Safety Monthly Reporting Plan |
6,000 |
Yes |
Yes |
57.108 |
Primary Bloodstream Infection (BSI) |
6,000 |
Yes |
Yes |
57.111 |
Pneumonia (PNEU) |
6,000 |
No |
Yes |
57.112 |
Ventilator-Associated Event |
6,000 |
Yes |
Yes |
57.114 |
Urinary Tract Infection (UTI) |
6,000 |
Yes |
Yes |
57.116 |
Denominators for Neonatal Intensive Care Unit (NICU) |
6,000 |
Yes |
Yes |
57.117 |
Denominators for Specialty Care Area (SCA)/Oncology (ONC) |
6,000 |
Yes |
Yes |
57.118 |
Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA) |
6,000 |
Yes |
Yes |
57.120 |
Surgical Site Infection (SSI) |
6,000 |
Yes |
Yes |
57.121 |
Denominator for Procedure |
6,000 |
Yes |
Yes |
57.123 |
Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables |
6,000 |
No |
No |
57.124 |
Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specification Tables |
6,000 |
No |
No |
57.125 |
Central Line Insertion Practices Adherence Monitoring |
1,000 |
No |
Yes |
57.126 |
MDRO or CDI Infection Form |
6,000 |
No |
Yes |
57.127 |
MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring |
6,000 |
Yes |
Yes |
57.128 |
Laboratory-identified MDRO or CDI Event |
6,000 |
Yes |
Yes |
57.137 |
Long-Term Care Facility Component – Annual Facility Survey |
250 |
No |
Yes |
57.138 |
Laboratory-identified MDRO or CDI Event for LTCF |
250 |
No |
Yes |
57.139 |
MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF |
250 |
No |
Yes |
57.140 |
Urinary Tract Infection (UTI) for LTCF |
250 |
No |
Yes |
57.141 |
Monthly Reporting Plan for LTCF |
250 |
No |
Yes |
57.142 |
Denominators for LTCF Locations |
250 |
No |
Yes |
57.143 |
Prevention Process Measures Monthly Monitoring for LTCF |
250 |
No |
No |
57.150 |
LTAC Annual Survey |
400 |
Yes |
Yes |
57.151 |
Rehab Annual Survey |
1,000 |
Yes |
Yes |
57.200 |
Healthcare Personnel Safety Component Annual Facility Survey |
50 |
No |
No |
57.203 |
Healthcare Personnel Safety Monthly Reporting Plan |
17,000 |
Yes |
Yes |
57.204 |
Healthcare Worker Demographic Data |
50 |
No |
No |
57.205 |
Exposure to Blood/Body Fluids |
50 |
No |
No |
57.206 |
Healthcare Worker Prophylaxis/Treatment |
50 |
No |
No |
57.207 |
Follow-Up Laboratory Testing |
50 |
No |
No |
57.210 |
Healthcare Worker Prophylaxis/Treatment-Influenza |
50 |
No |
No |
57.300 |
Hemovigilance Module Annual Survey |
500 |
No |
Yes |
57.301 |
Hemovigilance Module Monthly Reporting Plan |
500 |
No |
Yes |
57.303 |
Hemovigilance Module Monthly Reporting Denominators |
500 |
No |
Yes |
57.304 |
Hemovigilance Adverse Reaction |
500 |
No |
Yes |
57.305 |
Hemovigilance Incident |
500 |
No |
Yes |
57.400 |
Outpatient Procedure Component - Annual Facility Survey |
5,000 |
No |
No |
57.401 |
Outpatient Procedure Component - Monthly Reporting Plan |
5,000 |
No |
No |
57.402 |
Outpatient Procedure Component Event |
5,000 |
No |
No |
57.403 |
Outpatient Procedure Component - Monthly Denominators and Summary |
5,000 |
No |
No |
57.500 |
Outpatient Dialysis Center Practices Survey |
6,500 |
Yes |
Yes |
57.501 |
Dialysis Monthly Reporting Plan |
6,500 |
Yes |
Yes |
57.502 |
Dialysis Event |
6,500 |
Yes |
Yes |
57.503 |
Denominator for Outpatient Dialysis |
6,500 |
Yes |
Yes |
57.504 |
Prevention Process Measures Monthly Monitoring for Dialysis |
1,500 |
No |
No |
57.505 |
Dialysis Patient Influenza Vaccination |
325 |
No |
No |
57.506 |
Dialysis Patient Influenza Vaccination Denominator |
325 |
No |
No |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Amy Schneider-Webb |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |