Form CDC 57.105 CDC 57.105 Group Contact Information

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Group Contact Information

Page 1 of 1
*required for saving
NHSN Group Administrator
*First Name: __________________________________
Middle Name: _________________________________
*Last Name: __________________________________
*Group Name:_______________________________________________________________________
*Group Administrator’s Mailing Address:			____________________________________________________
			____________________________________________________
		*City:	____________________________________________________
		*State:	________________		*Zip Code:	________-________
		*Telephone Number:		( ) ____-______
		Extension:		_________________
		*Email: ______________________________________________
		A valid email account is required.
*Type of Group (check one type and one subtype, if applicable)
_______ Healthcare system (a group of institutions organized under a common business entity)
	_______ Private, for profit
	_______ Private, not for profit
_______ Governmental
	_______ City/county
	_______ State
	_______ Federal
_______ Quality Improvement/Patient Safety Organization
(a group of facilities defined by the desire to improve healthcare quality and patient outcomes)
_______ Other (describe): _______________________________________________________________
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 57.105 v6.6