Form 0920-1317 / CDC Fo 0920-1317 / CDC Fo Healthcare Personnel Safety Monthly Reporting Plan

Form Approved

OMB No. 0920-1317

Exp. Date: 11/30/2021

www.cdc.gov/nhsn

Healthcare Personnel Safety

Monthly Reporting Plan

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*required for saving
Facility ID#: ____________________________	*Month/Year: __________ /________
□ No NHSN Healthcare Personnel Safety Modules followed this month
Healthcare Personnel Exposure Modules
□ Blood/Body Fluid Exposure Only
□ Blood/Body Fluid Exposure with Exposure Management
□ Influenza Exposure Management
Healthcare Personnel Vaccination Module
□ Influenza Vaccination Summary
□ Influenza Vaccination Summary for the Hospital
□ Influenza Vaccination Summary for the Inpatient Rehabilitation Facility Unit(s)
□ Influenza Vaccination Summary for the Inpatient Psychiatric Facility Unit(s)
Weekly COVID-19 Vaccination Module
□ COVID-19 Vaccination Summary
□ COVID-19 Vaccination Summary for the Hospital
□ COVID-19 Vaccination Summary for the Inpatient Rehabilitation Facility Unit(s)
□ COVID-19 Vaccination Summary for the Inpatient Psychiatric Facility Unit(s)
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 5 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 57.203, v3, r8.4