Form CDC Form 57.141 CDC Form 57.141 Monthly Reporting Plan for LTCF

[NCEZID] National Healthcare Safety Network (NHSN) Coronavirus (COVID-19) Surveillance in Healthcare Facilities

57.141_ReportPlan_LTCF_July2021

Monthly Reporting Plan form for Long-term Care Facilities

OMB: 0920-1317

Document [docx]
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Form Approved

OMB No. 0920-1317

Exp. Date: 11/30/2021

www.cdc.gov/nhsn

Monthly Reporting Plan for LTCF

Page 1 of 1

*required for saving

Facility ID: __________________________

*Month/Year: ________ /_________

Healthcare Associated Infection (HAI)


+Locations

UTI


FacWideIN


LabID Event

+Locations

Specific Organism Type

±LabID Event All Specimens

FacWideIN

_______________


FacWideIN

_______________


FacWideIN

_______________


FacWideIN

_______________


FacWideIN

_______________


FacWideIN

_______________


FacWideIN

_______________


Prevention Process Measures

+Location

Hand Hygiene

Gown and Gloves Use


FACWIDEIN




Weekly COVID-19 Vaccination Module

Healthcare Personnel COVID-19 Vaccination Summary

Resident COVID-19 Vaccination Summary


+ FacWideIN = Facility-wide Inpatient

± LabID Event = Laboratory-identified Event


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, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666).


CDC 57.141 (Front), v7.0




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.141 LTCF Reporting Plan
SubjectNHSN OMB FORM 2018
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-05

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