Form CDC 57.403 CDC 57.403 Outpatient Procedure - Monthly Denominators and Summary

Form Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Outpatient Procedure Component

Denominators for Same Day Outcome Measures

Instructions for this form are available at: https://www.cdc.gov/nhsn/forms/instr/57.403-toi.pdf.

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*required for saving
Facility ID: ________________			*Month/Year: ________ /_________
Same Day Outcome Measures
*Total number of encounters for the month: __________				No Events Reported: 
Custom Fields
Label		Label
_____________________	____/____/____	_____________________			____/____/____
_____________________	____/____/____	_____________________			____/____/____
_____________________	____/____/____	_____________________			____/____/____
Comments
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 20 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 H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.403