Form CDC 57.142 CDC 57.142 Denominators for LTCF

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Denominators for LTCF

Page 1 of 1 **required for saving *conditionally required based on monitoring selection in Monthly Reporting Plan
Facility ID:		**Location Code:			**Month:	**Year:
Date	**Number of residents	*Number of residents with a urinary catheter	*New antibiotic starts for UTI indication	*Number of urine cultures ordered	*Number of admissions	*Number of admissions on C. diff treatment	*Number of C. diff treatment starts
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*Total
	Resident-days	Urinary-catheter days	Total antibiotic starts for UTI indication	Total urine cultures ordered	Resident-admissions	Resident-admissions on C. diff treatment
Label: _______ ________ _______ _________ ____________ ____________ Data: ________ ________ _______ _________ ___________ ____________
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 4.17hours 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 57.142 r3, v9.2