| Please list available information for all products used in the facility since May 1, 2022. If more than one product of a product type was used, please insert extra rows so that all products of that type are included. If more than one lot of a product was used during the time period, please include all lot numbers (if available). |
Form Approved OMB No. 0920-1011 Exp. Date 01/31/2023 |
| Product Type |
Product Name |
Manufacturer |
Product_Ref _number |
Product_Lot1 |
Product_Lot2 |
Product_Lot3 |
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| Hand hygiene |
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| hand sanitizer (all formulations used in clinic, including wipes) |
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| Hand soap – patient rooms |
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| Hand soap - bathrooms |
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| Hand lotion |
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| Other |
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| Antiseptic |
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| Alcohol swabs |
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| Chlorhexidine |
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| Povidone-Iodine Swabsticks |
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| Alcohol solution |
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| Hydrogen peroxide, 3% |
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| McKesson 3% hydrogen peroxide |
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| Other |
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| Oral care products |
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| Tap water |
N/A - but please indicate if used. |
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| Distilled water |
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| Sterile water |
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| Toothpaste |
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| Sponge swab |
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| Mouthwash |
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| Other |
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| Tube feeds |
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| Solutions used to flush enteral feedings |
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| Other |
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| Eye-Care Products |
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| Eye drops (list all ophthalmic solutions) |
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| Artificial tears (e.g. methylcellulose, hypromellose) |
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| GeriCare Liquid Tears |
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| Proparacaine Hydrochloride solution |
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| Altafluor Benox solution |
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| Timolol Maleate solution |
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| Rhoprossa solution |
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| Tropicamide solution |
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| Vyzulta solution |
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| Lactrilube |
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| Vita Pos |
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| fluoroscein eye drops |
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| Contact lens solution (all formulations) |
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| Saline, including saline bullets and saline rinse |
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| Other |
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| Products for bathing |
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| Saline, including saline bullets and saline rinse |
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| Distilled water |
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| Arrowhead brand distilled water |
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| Sterile water |
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| Other |
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| Topical products |
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| lubricants |
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| ointments |
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| lotions |
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| Other |
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| Cleaners and Disinfectants |
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| List all hospital grade disinfectants |
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| Hospital-grade bleach |
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| List all non-hospital grade cleaners and disinfectants |
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| windex |
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| Non-hospital grade bleach |
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| Fabuloso |
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| Formula 409 |
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| Tracheostomy care |
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| Trach care kit |
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| Saline product to clean around stoma site |
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| Hydrogen peroxide, 3% to clean around stoma site |
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| Ointment to clean around stoma site |
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| Other solutions/products used during tracheostomy care |
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| Wound care products |
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| Wound care kit |
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| Hydrogen peroxide, 3% |
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| Saline, including bullet(s) |
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| Distilled water |
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| Sterile water |
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| Other solutions/products used during wound care |
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| Inhaled products (including mists or sprays) |
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| Water used for humidifier circuit |
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| Diluent used for nebulizer |
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| Water used for CPAP/BiPAP |
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| Other inhaled products |
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| Urinary Catheter Supplies |
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| Catheter insertion kit(s) |
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| Lubricant |
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| Products used for other indications not listed above |
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| Ultrasound gel |
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| Other |
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| Public reporting burden of this collection of information is estimated to average 60 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/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011) |
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