Form CDC 57.200 CDC 57.200 Healthcare Personnel Safety - Annual Facility Survey

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Healthcare Personnel Safety Component—

Annual Facility Survey

Page 1 of 2
*required for saving
		Tracking #: ____________________________
Facility ID#: _________________________		*Survey Year: ___________
	*Facility Information	*Number of:
	Total beds set up and staffed
	Patient admissions
	Inpatient days
	Outpatient encounters
	Number of hours worked by all employees (from OSHA 300 log)
Enter Selected Healthcare Worker Occupational Groups on page 2.
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 8 hours 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 57.200 (Front), v6.6

Healthcare Personnel Safety Component—

Annual Facility Survey

Page 2 of 2
*Selected Healthcare Worker Occupational Groups
Occupation	Number of HCWs	Number of FTEs
Registered nurse
Licensed practical nurse
Nurse practitioner/clinical nurse specialist
Nurse assistant/patient care technician
Nurse midwife
Nurse anesthetist
Attendant/orderly
Respiratory technician/therapist
Phlebotomist
IV team
Medical laboratory technician
OR/surgical technician
Dental assistant/technician
Dental hygienist
Dentist
Housekeeper
Laundry staff
Maintenance/engineering service
Central supply staff
Physician assistants
Intern/resident
Fellow
Attending physician