CDC 57.204 Healthcare Worker Demographic Data

[NCEZID] The National Healthcare Safety Network (NHSN)

57.204_HCWDemographicData_BLANK

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Worker Demographic Data

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*required for saving

Facility ID#:

*HCW ID#:

Social Security #:

Secondary ID#:

HSW Name, Last:

First:

Middle:

Street Address:

City:

Sate:

Zip Code:

Home Phone: ( )

Email Address:

*Gender: F M Other

*Date of Birth: _____ /_____ /______

Born in U.S.? Yes No Unknown

Ethnicity: Hispanic or Latino

Race: American Indian or Alaskan Native

Not Hispanic or Not Latino

Asian


Black or African American


Native Hawaiian or Other Pacific Islander


White

Employment Information

Work Phone: ( )

*Start Date: _____ /_____ /______

*Work Status: Active Inactive No longer affiliated

*Type of employee: Full-time Part-time Contract employee Volunteer Other (specify)_________

*Work Location:

Department:

Supervisor:

*Occupation:

Title:

If occupation is physician, indicate clinical specialty (check one):

ANE – Anesthesiology

NRS – Neurosurgery

CAR – Cardiology

OBG – Obstetrics and Gynecology

CTS – Cardiothoracic Surgery

OPT – Ophthalmology

CRC – Critical Care

ORT – Orthopedics

DOS – Dentistry/Oral Surgery

OSS – Other Surgical Specialty

DER – Dermatology

OTH – Other Clinical Specialty

ENT – Ear, Nose and Throat

PAT – Pathology

ERM – Emergency Medicine

PED – Pediatrics

FAP – Family Practice

PLS – Plastic Surgery

GAS – Gastroenterology

PMR – Physical Medicine/Rehab

GEN – General Surgery/Trauma

PSC – Psychiatry

IND – Infectious Diseases

PUL – Pulmonology

INM – Internal Medicine

RAD – Radiology

MSU – Other Medical Subspecialty

URO – Urology

NEP – Nephrology

VAS – Vascular Surgery

NEU – Neurology


Performs direct patient care (i.e., hands on, face-to-face contact with patients for the purpose of diagnosis, treatment and/or monitoring):

Yes

No


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 20 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 57.204 (Front), v6.6

Healthcare Worker Demographic Data

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Custom Fields

Label

Label

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