Form CDC 57.139 CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitor

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

MDRO and CDI LabID Event Reporting

Monthly Summary Data for LTCF

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*required for saving

**conditionally required based upon monitoring selection in Monthly Reporting Plan

Facility ID #: ______________

*Month: ____________

*Year: __________

*Location Code: ____________

*Resident Days:______ *Resident Admissions:______

**Number of Admissions on C. diff Treatment:_______ **Number of C. diff Treatment Starts: _________

LabID Event Reporting

Specific Organism Type

MRSA

VRE

CephR-Klebsiella

CRE- E. coli

CRE- Enterobacter

CRE-Klebsiella

MDR-Acinetobacter

C.difficile

LabID Event (All specimens)

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Report No Events

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Custom Fields (Optional)

Label

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Data

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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 20 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 D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.139 rev 3, v.8.6