Form 57.133 Reporting Plan Venous Thromboembolism

Patient Safety Form Approved

OMB No. 0920-0666

Exp. Date:  06/30/2026

www.cdc.gov/nhsn

Venous Thromboembolism Module

Digital Measure Reporting Plan (CDC 57.133)

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*required for saving

Facility ID: ______________*Start Month: _______*Start Year: _________ *End Month: ________ *End Year: ________

Measure

Venous Thromboembolism (VTE) Module

Venous Thromboembolism (VTE) Module: VTE Module data is collected by facility and include all inpatient locations, emergency departments, 24-hour observation units.

Measure Venous Thromboembolism (VTE) Module Reporting

Following ☐

*required for saving

Facility ID: _______*Start Month: _______*Start Year: ______ End Month: ________ End Year: ________

Notes: During the specified reporting period, the facility authorizes NHSN to query your facility’s FHIR server to collect the specified data elements as per the NHSN VTE Module protocol. Based on these data, your facility will be provided with measure results reflecting total percentage rates (for example, VTE-1 total percentage), as well as additional analytic and reporting options (for example, line-level lists).

• To participate in the NHSN VTE Module, a Patient Safety Annual Survey must be completed and submitted. The survey must be completed annually and submitted by the end of February. This will allow addition of reporting plans for the current year. Data will only be pulled when there is a completed annual survey.

• Completion of the reporting plan indicates that data transmitted by your facility conforms to the NHSN VTE Module protocol in entirety during the specified reporting period. This includes ensuring that all local codes used by your facility (for example, medications) are mapped to established value sets (for example, RXNORM) as defined in the protocol.

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 6 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 57.133(Front) Rev.12.4, v 1.0,

CDC 57.133 (Back) Rev.12.4, v 1.0,