Form 57.404 Outpatient Procedure Component - SSI Denominators

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Outpatient Procedure Component

Denominator for Procedure

Page 1 of 1				*required for saving
Facility ID			Procedure #:
*Patient ID:			Social Security #:
Secondary ID:			Medicare #:
Patient Name, Last:			First:		Middle:
*Gender: F M Other			*Date of Birth:
Ethnicity (Specify):			Race (Specify):
Event Type: PROC			*NHSN Procedure Code Category:
*Date of Procedure:			CPT Procedure Code:
Procedure Details
*Wound Class: C CC CO D				*Duration: ______Hours ______Minutes
*ASA Score: 1 2 3 4 5				*General Anesthesia: Yes No
*Endoscope: Yes No				*Diabetes Mellitus: Yes No
Surgeon Code: __________
*Height: (choose one) ______feet ______inches ______meters				*Weight: _______ lbs/kg (circle one)
Custom Fields
Label				Label
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
______________________	___ /____/______			______________________		___ /____/______
Comments
Assurance of Confidentiality: The 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 average10 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 57.404, v9.0