Form Approved
OMB No. 0920-0666
Exp. Date: xx/xx/20xx
www.cdc.gov/nhsn
Patient Safety Monthly Reporting Plan Page 1 of 2 |
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Facility ID: _____________________________ |
*Month/Year: ___________ /______ |
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□ No NHSN Patient Safety Modules Followed this Month |
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Device-Associated Module |
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Locations |
CLABSI |
VAE |
CAUTI |
CLIP |
PedVAP |
PedVAE |
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Procedure-Associated Module |
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Procedures |
SSI |
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IN OUT |
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Antimicrobial Use and Resistance Module |
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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
Page 2 of 2 |
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MDRO and CDI Module |
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+Locations |
Specific Organism Type |
±LabID Event |
±LabID Event |
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(Circle one) |
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All Specimens |
Blood specimens only |
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FacWideIN |
FacWideOUT |
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FacWideIN |
FacWideOUT |
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FacWideIN |
FacWideOUT |
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FacWideIN |
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Process and Outcome Measures |
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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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Adm Both |
All NHx |
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All NHx |
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All NHx |
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Adm Both |
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
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | 57.106 |
Subject | NHSN OMB FORM 2018 |
Author | CDC/NCZEID/DHQP |
File Modified | 0000-00-00 |
File Created | 2021-02-27 |