Form CDC 57.200 CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey

[NCEZID] The National Healthcare Safety Network (NHSN)

57.200_AnnualFacSurv_BLANK

57.200 Healthcare Personnel Safety Component Facility Survey

OMB: 0920-0666

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Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Personnel Safety Component—

Annual Facility Survey

Page 1 of 2

*required for saving


Tracking #: ____________________________

Facility ID#: _________________________

*Survey Year: ___________


*Facility Information

*Number of:



Total beds set up and staffed




Patient admissions




Inpatient days




Outpatient encounters




Number of hours worked by all employees (from OSHA 300 log)



Enter Selected Healthcare Worker Occupational Groups on page 2.























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 8 hours 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 57.200 (Front), v6.6

Healthcare Personnel Safety Component—

Annual Facility Survey

Page 2 of 2

*Selected Healthcare Worker Occupational Groups

Occupation

Number of HCWs

Number of FTEs

Registered nurse



Licensed practical nurse



Nurse practitioner/clinical nurse specialist



Nurse assistant/patient care technician



Nurse midwife



Nurse anesthetist



Attendant/orderly



Respiratory technician/therapist



Phlebotomist



IV team



Medical laboratory technician



OR/surgical technician



Dental assistant/technician



Dental hygienist



Dentist



Housekeeper



Laundry staff



Maintenance/engineering service



Central supply staff



Physician assistants



Intern/resident



Fellow


Attending physician



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AuthorAmy Schneider
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File Created2023-11-20

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