Form 57.132 Reporting Plan HOB and HTCDI

Form Approved

OMB No. 0920-0666

Exp. Date:  12/31/2026

www.cdc.gov/nhsn

Patient Safety Component Digital Measure Reporting Plan (CDC 57.132)

Page 1 of 1

*required for saving

Facility ID: ______________*

Measure

Healthcare facility onset, antibiotic treated CDI (HT-CDI)

HT-CDI data are collected from and include all applicable inpatient locations, emergency departments, and 24-hour observation units.

Measure HT-CDI

Following ☐

Start Month*

Start Year*

End Month

End Year

CDI Test Type/Algorithm * Specify Other		Month	Year

Hospital onset bacteria (HOB)

HOB data are collected from and include all applicable inpatient locations, emergency departments, and 24-hour observation units.

Measure HOB

Following ☐

Start Month*

Start Year*

End Month

End Year

Venous Thromboembolism (VTE) Module

Venous Thromboembolism (VTE) Module: VTE Module data are collected by facility and include all inpatient locations, emergency departments, 24-hour observation units.

Measure Venous Thromboembolism (VTE)

Following ☐

Start Month*

Start Year*

End Month

End Year

Nonventilator Hospital-acquired Pneumonia (NVHAP) Event Module

Nonventilator Hospital-acquired Pneumonia (NVHAP) Module: NVHAP Module data are collected from inpatient locations.

Measure NVHAP

Following ☐

Start Month*

Start Year*

End Month

End Year

Adult Sepsis Event Module

Adult Sepsis Module: Adult Sepsis Module data are collected from and include inpatient locations.

Measure

Adult Sepsis

Following

☐

Start Month*

Start Year*

End Month

End Year

Respiratory Pathogens Surveillance (RPS) Module

Respiratory Pathogens Surveillance (RPS) Module: RPS Module data are collected from and include all inpatient locations, emergency departments, and 24-hour observation units.

Required. Select one: CSV or FHIR.

Measure RPS

CSV ☐

FHIR ☐

Start Month*

Start Year*

End Month

End Year

Note: Either CSV or FHIR must be selected. Both options cannot be selected for the same month/year.

*If Following is selected, Start Month and Start Year are required for that measure.

Notes:

• During the specified reporting period, if FHIR is selected the facility authorizes NHSN to query your facility’s FHIR server to collect the specified data elements as per the NHSN Patient Safety Component Digital Quality Measure (dQM) protocols for each of the modules that appear on this form. The data collected will be used to provide measure specific event rates for each measure followed, as well as additional analytic and reporting options (for example, line-level lists).

• To participate in any of the NHSN Patient Safety Component dQM modules, a Patient Safety Annual Survey must be completed and submitted. The survey must be completed annually and submitted by the end of February. This will allow addition of reporting plans for the current year. Data will only be pulled when there is a completed annual survey.

• Completion of the reporting plan indicates that data transmitted by your facility conforms to the NHSN dQM protocol(s) for the measures your facility elected to follow and instructions for reporting FHIR dQMs to NHSN. This includes adherence to technical specifications for value sets (i.e., local or non-standardized codes are mapped to established value sets such as RxNorm, LOINC, and HSLOC).

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 10 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 57.132 (Back) Rev. 5, 9.2