Form 57.106 Patient Safety Monthly Reporting Plan

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2021

www.cdc.gov/nhsn

Patient Safety Monthly Reporting Plan Page 1 of 2
*required for saving
Facility ID: _____________________________		*Month/Year: ___________ /______
□ No NHSN Patient Safety Modules Followed this Month
Device-Associated Module
Locations	CLABSI	VAE	CAUTI	CLIP	PedVAP	PedVAE
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
_________________________________	□	□	□	□	□	□
Procedure-Associated Module
Procedures	SSI
	IN OUT
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
_________________________________	□ □
Antimicrobial Use and Resistance Module
Locations	Antimicrobial Use			Antimicrobial Resistance
_________________________________	□			□
_________________________________	□			□
_________________________________	□			□
_________________________________	□			□
_________________________________	□			□
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 15 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 57.106(Front) Rev. 5, v9.2

Patient Safety Monthly Reporting Plan

Page 2 of 2
MDRO and CDI Module
+Locations			Specific Organism Type			±LabID Event		±LabID Event
(Circle one)						All Specimens		Blood specimens only
FacWideIN	FacWideOUT		______________			□		□
FacWideIN	FacWideOUT		______________			□		□
FacWideIN	FacWideOUT		______________			□		□
FacWideIN	FacWideOUT		______________			□		□
Process and Outcome Measures
Locations	Specific Organism Type	Infection Surveillance		§AST Timing	§AST Eligible	Incidence	Prevalence		LabID Event	HH	GG
__________	________	□		Adm Both	All NHx	□	□		□	□	□
__________	________	□		Adm Both	All NHx	□	□		□	□	□
__________	________	□		Adm Both	All NHx	□	□		□	□	□
__________	________	□		Adm Both	All NHx	□	□		□	□	□
__________	________	□		Adm Both	All NHx	□	□		□	□	□
+ FacWideIN = Facility-wide Inpatient FacWideOUT = Facility-wide Outpatient NHx = Only patients tested are those who have no documentation at the admitting facility in the previous 12 months of MDRO-colonization or infection at the time of admission. ± LabID Event = Laboratory-identified Event § For AST, circle one choice to indicate time of testing and one choice to indicate type of patients eligible for testing. Timing: Adm = Admission Both = Both Admission and Discharge/Transfer Patients Eligible: All patients tested