Form CDC 57.116 CDC 57.116 PedVAE Optional Denominators Neonatal Intensive Care Uni

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Denominators for Neonatal Intensive Care Unit (NICU)

Page 1 of 4

*Required for saving

**Conditionally required according to the events indicated in Plan

Facility ID:

*Location Code:

*Month:

*Year:

Birth Weight Categories

Date:

≤750 g

751-1000 g

1001-1500 g

1501-2500 g

>2500 g

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

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 hours 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 57.116(Front), Rev 2 v9.2 Continued >>>

Page 2 of 4

*Required for saving

**Conditionally required according to the events indicated in Plan

Birth Weight Categories (continued)

Date:

≤750 g

751-1000 g

1001-1500 g

1501-2500 g

>2500 g

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

Pt*

**CL

**VNT

UrC

EMV

24.

25.

26.

27.

28.

29.

30.

31.

*Total

Pt=number of infants CL=number of infants with 1 or more central lines, including umbilical catheter VNT=number of infants on a ventilator UrC=number of infants with a urinary catheter EMV= Episodes of mechanical ventilation

Label _______________ _______________ _______________ _______________ _______________ Data _______________ _______________ _______________ _______________ _______________

PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)

Page 3 of 4

*Required for Saving

**Conditionally required according to the events indicated in the plan

Facility ID :

*Location Code:

*Month:

*Year:

Gestational Age Categories

Date:

Extremely preterm

(<28 weeks)

Very preterm

(28 to <32 weeks)

Moderate to late preterm

(32 to <37 weeks)

Term

(≥37 weeks)

PT

VNT

EMV

PT

VNT

EMV

PT

VNT

EMV

PT

VNT

EMV

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

Page 4 of 4

*Required for saving

**Conditionally required according to the events indicated in Plan

Gestational Age Categories (continued)

Date:

Extremely preterm

(<28 weeks)

Very preterm

(28 to <32 weeks)

Moderate to late preterm

(32 to <37 weeks)

Term

(≥37 weeks)

PT

VNT

EMV

PT

VNT

EMV

PT

VNT

EMV

PT

VNT

EMV

26.

27.

28.

29.

30.

31.

*Total

Pt=number of infants VNT=number of infants on a ventilator EMV= Episodes of mechanical ventilation

Label	_______________	_______________	_______________	_______________	_______________
Data	_______________	_______________	_______________	_______________	_______________