57.155 NHSN - Point of Care Testing Results - LTCF personnel (r

F orm Approved

OMB No. XXXX-XXXX

Exp. Date: XX/XX/XXXX

www.cdc.gov/nhsn

Point of Care Testing Results

NOTE: Submission of data elements on this form is agreement for CDC to convert and electronically transmit the data to the State and local health departments as a part of communicable disease surveillance and control and to assist in meeting reporting requirements.

Page 1 of 1	*required for saving ^conditionally required
Facility ID:				*Type of Individual Tested:
^Resident ID:			^Staff ID:
*First Name:		Middle Name:			*Last Name:
*Gender: F M Other			*Date of Birth:
*Ethnicity (Specify):			*Race (Specify):
*Address, line 1			^Address, line 2
*City:			*State:
*Zip Code:			*County:
*Contact Phone:			Ext:
POC Test Results
*Test Date:
*Device Name:
*Specimen Source:
*Test Result:
*Specimen Number:
*Ordering Physician:
*Was person symptomatic?
*Was person pregnant?
Ordering Physician
Address, line 1						Address, line 2
City:						State:
*Zip Code:
Work Phone:						Ext:
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 10 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 57.155 (Front) Rev. 11 v9.4