CDC 57.143 Prevention Process Measures Monthly Monitoring

[NCEZID] The National Healthcare Safety Network (NHSN)

57.143_ProcessMeasureSummaryforLTCF_BLANK.DOCX

OMB: 0920-0666

Document [docx]
Download: docx | pdf

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Prevention Process Measures Monthly Monitoring for LTCF

Page 1 of 1


*required for saving

**conditionally required based upon monitoring selection in Monthly Reporting Plan

Facility ID #: _________

*Month: ___________

*Year: ____________

*Location Code: ______


Prevention Process Measures

Hand Hygiene

Gown and Gloves

**Performed: _______

**Used: ___________

**Indicated: ________

**Indicated: ________











Custom Fields

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 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 57.143 v.7.0




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.143 LTCF Process Measures
AuthorAmy Schneider;CDC
File Modified0000-00-00
File Created2023-08-30

© 2024 OMB.report | Privacy Policy