0920-0666 Form 57.130 Pathogens of High Consequence2_0DEC2024

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

www.cdc.gov/nhsn

Infectious Diseases of Public Health Concern Form

*Required for submission

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

The Infectious Disease of Public Health Concern form collects information regarding number of patients newly admitted and currently hospitalized with certain diseases in acute care hospitals. Please first select the disease(s) for which you are reporting data in the drop-down menu below, and then fill out the requested information in the form, as applicable.

For overall total number of patients with confirmed or unconfirmed disease, please include all patients newly admitted as well as patients currently hospitalized for a given reporting date.

For stratifications, please provide the numbers of adult and pediatric patients newly admitted and currently hospitalized for a given reporting date, separately, and by confirmed and unconfirmed disease status. For further guidance, please refer to the Table of Instructions (TOI).

2. Entering Data For* (select disease from drop-down menu):

Crimean-Congo Hemorrhagic Fever (CCHF) Dengue Ebola Influenza A (H5) Lassa Marburg Measles Mpox MERS-CoV Nipah Oropouche Polio Toxigenic Vibrio cholerae

Disease:
Patients with confirmation of disease	Patients with unconfirmed disease
3a. Total number all hospitalized patients with confirmed disease	4a. Total number all hospitalized patients with unconfirmed disease
Adult patients	Adult patients
3b. Number of new admissions of adult patients with confirmed disease	4b. Number of new admissions of adult patients with unconfirmed disease
3c. All hospitalized adult patients with confirmed disease	4c. All hospitalized adult patients with unconfirmed disease
Pediatric patients	Pediatric patients
3d. Number of new admissions of pediatric patients with confirmed disease	4d. Number of new admissions of pediatric patients with unconfirmed disease
3e. All hospitalized pediatric patients with confirmed disease	4e. All hospitalized pediatric patients with unconfirmed disease

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 March 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). For reference, the estimated to average 30 minutes per response is taken from the Avg. Burden per Response (Min./Hour) column on the burden table located on this form.