Form CDC 57.501 CDC 57.501 NHSN Registration Form

Form Approved

Dialysis Component

Monthly Reporting Plan

OMB No. 0920-0666

Exp. Date: 01/31/2021

www.cdc.gov/nhsn

Select the surveillance module checkbox(es) to inform CDC that those data are being collected and reported as specified by their corresponding surveillance protocol(s).

*required for saving					Page 1 of 1
*Facility ID: _____________________________			*Month/Year: ___________ /_________
□ Not Participating in NHSN this Month
Events
Locations:						Dialysis Event (DE)		Central Line Insertion Practices (CLIP)
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Prevention Process Measures
Location:	Hand Hygiene	HD Catheter Connection/ Disconnection		HD Catheter Exit Site Care			AV Fistula & Graft Cannulation/ Decannulation	Dialysis Station Routine Disinfection	Injection Safety – Medication Preparation	Injection Safety – Medication Administration
_____________________	□	□		□			□	□	□	□
Patient Vaccination
Influenza Vaccination - Dialysis Patients:		□
Comments
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 5 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, Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0666). CDC 57.501 Rev 3, v8.8