Form
Approved
OMB No. 0920-1317
Exp. Date: 11/30/2021
www.cdc.gov/nhsn
Monthly Reporting Plan for LTCF
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*required for saving |
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Facility ID: __________________________ |
*Month/Year: ________ /_________ |
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Healthcare Associated Infection (HAI) |
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+Locations |
UTI |
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FacWideIN |
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LabID Event |
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+Locations |
Specific Organism Type |
±LabID Event All Specimens |
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FacWideIN |
_______________ |
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FacWideIN |
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FacWideIN |
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FacWideIN |
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FacWideIN |
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FacWideIN |
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FacWideIN |
_______________ |
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Prevention Process Measures |
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+Location |
Hand Hygiene |
Gown and Gloves Use |
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FACWIDEIN |
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Weekly COVID-19 Vaccination Module |
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□ Healthcare Personnel COVID-19 Vaccination Summary □ Resident COVID-19 Vaccination Summary
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+ FacWideIN = Facility-wide Inpatient ± LabID Event = Laboratory-identified Event |
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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 57.141 (Front), v7.0 |
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 0000-00-00 |