Form 57.801 External Validation Summary Report

Form Approved

OMB No. 0920-0666

Exp. Date:  12/31/2026

www.cdc.gov/nhsn

External Validation Summary Report

 

Jurisdiction name
Contact in case of follow-up:
HAI validated
Year (or timeframe) of data reviewed
Facility selection method
Number of facility refusals, and reason(s) provided for refusal
Was the NHSN External Validation Toolkit (EVT) used? If partly, what was used?	Yes No Partially Used (specify):
If NHSN EVT was not used, please describe the facility and record selection process.
Common errors identified across facilities
How many health department staff worked on validation activities? Average time spent working on validation?
Once completed, email this form to: [email protected], using the phrase “External Validation” in the subject line.

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, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0666).