CDC 57.501 NHSN Registration Form

[NCEZID] The National Healthcare Safety Network (NHSN)

57.501_DialReportPlan_BLANK_2021_final draft for omb

OMB: 0920-0666

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Form Approved

Shape1

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)

_____________________________________________________

_____________________________________________________

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



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File Title57.501
SubjectNHSN OMB FORM 2018
AuthorCDC/NCZEID/DHQP
File Modified0000-00-00
File Created2024-09-16

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