Document
57.501
ICR 202212-0920-013 · OMB 0920-0666 · Object 127512801.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | 57.501 |
| Subject | NHSN OMB FORM 2018 |
| Keywords | Dialysis, Component, MONTHLY, REPORTING, PLAN |
| Author | CDC/NCZEID/DHQP |
| Last Modified By | Writer |
| File Modified | 2020-05-21 |
| File Created | 2026-10-10 |
| Conversion State | complete |
Extracted Text
Select the surveillance module checkbox(es) to inform CDC that those data are being collected and reported as specified by their corresponding surveillance protocol(s). *required for saving Page 1 of 1 *Facility ID: _____________________________ *Month/Year: ___________ /_________ □ Not Participating in NHSN this Month Events Locations: Dialysis Event (DE) Central Line Insertion Practices (CLIP) _____________________________________________________ □ □ □ _____________________________________________________ □ Prevention Process Measures Location: Hand Hygiene HD Catheter Connection/ Disconnection HD Catheter Exit Site Care AV Fistula & Graft Cannulation/ Decannulation Dialysis Station Routine Disinfection Injection Safety – Medication Preparation Injection Safety – Medication Administration _____________________ □ □ □ □ □ □ □ Patient Vaccination Influenza Vaccination - Dialysis Patients: □ Comments 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, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.501 Rev 3, v8.8