Form CDC 57.143 CDC 57.143 Prevention Process Measures Monthly Monitoring

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Prevention Process Measures Monthly Monitoring for LTCF

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*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