CDC 57.106 Patient Safety Monthly Reporting Plan

The National Healthcare Safety Network (NHSN)

57.106_PS ReportPlan_BLANK

OMB: 0920-0666

Document [docx]
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Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Patient Safety Monthly Reporting Plan

Page 1 of 2

*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

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

Procedure-Associated Module

Procedures

SSI



IN OUT


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


_________________________________

□ □


Antimicrobial Use and Resistance Module

Locations

Antimicrobial Use

Antimicrobial Resistance

_________________________________

_________________________________

_________________________________

_________________________________

_________________________________

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

MDRO and CDI Module

+Locations

Specific Organism Type

±LabID Event

±LabID Event

(Circle one)


All Specimens

Blood specimens only

FacWideIN

FacWideOUT

______________

FacWideIN

FacWideOUT

______________

FacWideIN

FacWideOUT

______________

FacWideIN

FacWideOUT

______________

Process and Outcome Measures

Locations

Specific Organism Type

Infection Surveillance

§AST Timing

§AST Eligible

Incidence

Prevalence

LabID Event

HH

GG

__________

________

Adm Both

All NHx

__________

________

Adm Both

All NHx

__________

________

Adm Both

All NHx

__________

________

Adm Both

All NHx

__________

________

Adm Both

All NHx



+ 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





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.106
SubjectNHSN OMB FORM 2018
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2021-02-27

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