Form CDC 57.402 CDC 57.402 Outpatient Procedure - Event

OMB 0920-0666

Exp. Date xx-xx-xxxx

www.cdc.gov/nhsn

Outpatient Procedure Component Same Day Outcome Measures

This form is used for reporting data on each patient having experienced one or more of the same day outcome measures events.

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*required for saving

Facility ID:

Event #:

*Patient ID:

Social Security #:

Secondary ID #:

Medicare #:

Patient Name

Last:

First:

Middle:

*Gender: F M Other

*Date of Birth:

Ethnicity (Specify):

Race (Specify):

*Date of Encounter (Admission) at the Outpatient Procedure Center (MM/DD/YYYY):

Same Day Outcome Measures

*Specify event: (check all that apply)

□ Patient burn

□ Patient fall

□ Hospital transfer/admission

Wrong Event (any that apply)

□ Wrong side

□ Wrong patient

□ Wrong implant

□ Wrong site

□ Wrong procedure

Custom Fields

Label

Label

___ / ___ / ___

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___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

___ / ___ / ___

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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 40 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 57.402, r1,v9.0