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

Form Approved

OMB No. 0920-1317

Exp. Date: 11/30/2021

www.cdc.gov/nhsn

Monthly Reporting Plan for LTCF

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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