Form 57.130 Pathogens of High Consequence

Form Approved

OMB No. 0920-0666

Exp. Date 12/31/2026

www.cdc.gov/nhsn

Pathogens of High Consequence Form

*Required for submission

Facility Information
1	a.	NHSN Org ID*
	b.	Reporting for Date*

The Pathogens of High Consequence form is collecting incidence (newly identified cases) and prevalence (existing cases) data for inpatients with the listed diseases/pathogens in Acute Care Hospitals. First, select the pathogen(s) you are reporting for in the drop-down menu below, and then proceed to fill out the form, as applicable. Determine the total number of confirmed and unconfirmed cases for each pathogen, and then further stratify by patient population and incident versus prevalent cases. For further guidance, please refer to the Table of Instructions (TOI).

2. Entering Data For* (select pathogen):

Crimean-Congo Haemorrhagic Fever (CCHF)
3a. Confirmed Total cases of CCHF	4a. Unconfirmed Total cases of CCHF
3b. Confirmed adult newly identified case	4b. Unconfirmed adult newly identified case
3c. Confirmed adult existing case	4c. Unconfirmed adult existing case
3d. Confirmed pediatric newly identified case	4d. Unconfirmed pediatric newly identified case
3e. Confirmed pediatric existing case	4e. Unconfirmed pediatric existing case

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)). CDC 57.130 Rev (13.1.0 February 2025).

Public reporting burden of this collection of information is estimated to average 30 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).

Dengue Virus
5a. Confirmed Total cases of Dengue Virus	6a. Unconfirmed Total cases of Dengue Virus
5b. Confirmed adult newly identified case	6b. Unconfirmed adult newly identified case
5c. Confirmed adult existing case	6c. Unconfirmed adult existing case
5d. Confirmed pediatric newly identified case	6d. Unconfirmed pediatric newly identified case
5e. Confirmed pediatric existing case	6e. Unconfirmed pediatric existing case

Ebola Virus
7a. Confirmed Total cases of Ebola Virus	8a. Unconfirmed Total cases of Ebola Virus
7b. Confirmed adult newly identified case	8b. Unconfirmed adult newly identified case
7c. Confirmed adult existing case	8c. Unconfirmed adult existing case
7d. Confirmed pediatric newly identified case	8d. Unconfirmed pediatric newly identified case
7e. Confirmed pediatric existing case	8e. Unconfirmed pediatric existing case

Lassa Fever
9a. Confirmed Total cases of Lassa Fever	10a. Unconfirmed Total cases of Lassa Fever
9b. Confirmed adult newly identified case	10b. Unconfirmed adult newly identified case
9c. Confirmed adult existing case	10c. Unconfirmed adult existing case
9d. Confirmed pediatric newly identified case	10d. Unconfirmed pediatric newly identified case
9e. Confirmed pediatric existing case	10e. Unconfirmed pediatric existing case

Measles
11a. Confirmed Total cases of Measles	12a. Unconfirmed Total cases of Measles
11b. Confirmed adult newly identified case	12b. Unconfirmed adult newly identified case
11c. Confirmed adult existing case	12c. Unconfirmed adult existing case
11d. Confirmed pediatric newly identified case	12d. Unconfirmed pediatric newly identified case
11e. Confirmed pediatric existing case	12e. Unconfirmed pediatric existing case

Mpox
13a. Confirmed Total cases of Mpox	14a. Unconfirmed Total cases of Mpox
13b. Confirmed adult newly identified case	14b. Unconfirmed adult newly identified case
13c. Confirmed adult existing case	14c. Unconfirmed adult existing case
13d. Confirmed pediatric newly identified case	14d. Unconfirmed pediatric newly identified case
13e. Confirmed pediatric existing case	14e. Unconfirmed pediatric existing case

MERS-CoV
15a. Confirmed Total cases of MERS-CoV	16a. Unconfirmed Total cases of MERS-CoV
15b. Confirmed adult newly identified case	16b. Unconfirmed adult newly identified case
15c. Confirmed adult existing case	16c. Unconfirmed adult existing case
15d. Confirmed pediatric newly identified case	16d. Unconfirmed pediatric newly identified case
15e. Confirmed pediatric existing case	16e. Unconfirmed pediatric existing case

Nipah Virus
17a. Confirmed Total cases of Nipah Virus	18a. Unconfirmed Total cases of Nipah Virus
17b. Confirmed adult newly identified case	18b. Unconfirmed adult newly identified case
17c. Confirmed adult existing case	18c. Unconfirmed adult existing case
17d. Confirmed pediatric newly identified case	18d. Unconfirmed pediatric newly identified case
17e. Confirmed pediatric existing case	18e. Unconfirmed pediatric existing case

Toxigenic Vibrio cholerae
19a. Confirmed Total cases of Toxigenic Vibrio cholerae	20a. Unconfirmed Total cases of Toxigenic Vibrio cholerae
19b. Confirmed adult newly identified case	20b. Unconfirmed adult newly identified case
19c. Confirmed adult existing case	20c. Unconfirmed adult existing case
19d. Confirmed pediatric newly identified case	20d. Unconfirmed pediatric newly identified case
19e. Confirmed pediatric existing case	20e. Unconfirmed pediatric existing case