57.106

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Patient Safety Monthly Reporting Plan
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*required for saving
Facility ID: _____________________________
*Month/Year: ___________ /______
□ No NHSN Patient Safety Modules Followed this Month
Device-Associated Module
Locations
CLABSI
VAE
CAUTI
CLIP
PedVAP
PedVAE
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Procedure-Associated Module
Procedures
SSI


IN         OUT

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Antimicrobial Use and Resistance Module
Locations
Antimicrobial Use
Antimicrobial Resistance
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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, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666).
CDC 57.106(Front) Rev. 5,  v9.2
Patient Safety Monthly Reporting Plan
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MDRO and CDI Module
+Locations
Specific Organism Type
±LabID Event
±LabID Event
(Circle one)

All Specimens
Blood specimens only
FacWideIN
FacWideOUT
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FacWideIN
FacWideOUT
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FacWideOUT
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Process and Outcome Measures
Locations
Specific Organism Type
Infection Surveillance
§AST Timing
§AST Eligible
Incidence
Prevalence
LabID Event
HH
GG
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Adm Both
All     NHx
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All     NHx
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All     NHx
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+ FacWideIN = Facility-wide Inpatient
FacWideOUT = Facility-wide Outpatient
NHx = Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission.
± LabID Event = Laboratory-identified Event
§ For AST, circle one choice to indicate time of testing and one choice to indicate type of patients eligible for testing.
Timing: Adm = Admission
Both = Both Admission and Discharge/Transfer
Patients Eligible: All patients tested