Att E1_NHSN forms used for CMS QRPs and State Mandated Reporting

National Healthcare Safety Network (NHSN)

OMB Control No. 0920-0666

Revision Request May 2016

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
57.113	Pediatric Ventilator-Associated Event (PedVAE)	2,000	No	No
57.114	Urinary Tract Infection (UTI)	6,000	Yes	Yes
57.115	Custom Event	2,000	No	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	Yes	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
57.129	Adult Sepsis	50	No	No
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 – Acute Care Facility	500	No	Yes
57.301	Hemovigilance Module Monthly Reporting Plan	500	No	Yes
57.303	Hemovigilance Module Monthly Reporting Denominators	500	No	Yes
57.305	Hemovigilance Incident	500	No	Yes
57.306	Hemovigilance Module Annual Survey – Non-Acute Care Facility	200	No	No
57.307	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	500	No	No
57.308	Hemovigilance Adverse Reaction - Allergic Transfusion Reaction	500	No	No
57.309	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	500	No	No
57.310	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	500	No	No
57.311	Hemovigilance Adverse Reaction - Febrile Non-hemolytic Transfusion Reaction	500	No	No
57.312	Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction	500	No	No
57.313	Hemovigilance Adverse Reaction - Infection	500	No	No
57.314	Hemovigilance Adverse Reaction - Post Transfusion Purpura	500	No	No
57.315	Hemovigilance Adverse Reaction - Transfusion Associated Dyspnea	500	No	No
57.316	Hemovigilance Adverse Reaction - Transfusion Associated Graft vs. Host Disease	500	No	No
57.317	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury	500	No	No
57.318	Hemovigilance Adverse Reaction - Transfusion Associated Circulatory Overload	500	No	No
57.319	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	500	No	No
57.320	Hemovigilance Adverse Reaction - Other Transfusion Reaction	500	No	No
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
57.507	Home Dialysis Center Practices Survey	600	Yes	No

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