CDC 57.142 Denominators for LTCF

[NCEZID] The National Healthcare Safety Network (NHSN)

57.142_DenominatorLTCF_ update for RP module_clean

OMB: 0920-0666

Document [docx]
Download: docx | pdf


Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Denominators for LTCF

Page 1 of 1 **Required for saving *Conditionally required based on monitoring selection in Monthly Reporting Plan

Facility ID:

**Location Code:

**Month:

**Year:

Date

**Number of Residents

*Number of residents with a urinary catheter

*New antibiotic starts for UTI indication

*Number of urine cultures ordered

*Resident Admissions

*Number of admissions on C. diff treatment

*Number of Residents Started on Antibiotic Treatment for C. diff

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*Monthly Total

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Total resident days

Urinary-Catheter Days

New antibiotic starts for UTI indication

Number of urine cultures ordered

Resident admissions

Resident admissions on C. diff treatment

Number of residents started on antibiotic treatment for C. diff

Label: _______ ________ _______ _________ ____________ ____________

Data: ________ ________ _______ _________ ___________ ____________









*This section is NOT editable by the user; this section is populated from data entered for the weekly vaccination summary in the NHSN LTC Vaccination Module

Weekly Vaccination summary data

Month: _______

Week 1

Total residents____

Number of residents who are up to date with COVID-19 vaccinations_____

Number of residents who are up to date with Influenza vaccinations_____

Number of residents who are up to date with RSV vaccinations_____

Week 2

Total residents____

Number of residents who are up to date with COVID-19 vaccinations___


Number of residents who are up to date with Influenza vaccinations_____

Number of residents who are up to date with RSV vaccinations_____

Week 3

Total residents____

Number of residents who are up to date with COVID-19 vaccinations___


Number of residents who are up to date with Influenza vaccinations_____

Number of residents who are up to date with RSV vaccinations_____

Week 4

Total residents____

Number of residents who are up to date with COVID-19 vaccinations_____

Number of residents who are up to date with Influenza vaccinations_____

Number of residents who are up to date with RSV vaccinations_____







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 35 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 57.142 r4, v12.0



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.142 Denominators Form for LTCF
Subject57.142 Denominators Form for LTCF
AuthorCDC/NCEZID/DHQP
File Modified0000-00-00
File Created2024-09-16

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