Form Cdc 57 117 – Fill Out and Use This PDF

Form Approved

OMB No. 0920-0666

Exp. Date: 10/31/2016

www.cdc.gov/nhsn

Denominators for Specialty Care Area (SCA)/Oncology (ONC)

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		*required for saving
		Facility ID:						*Location Code:							*Month:			*Year:
								**Number of patients with 1 or more
		Date			*Number										**Number of patients				**Number of patients on
									central lines
					of Patients										with a urinary catheter					a ventilator
								(if patient has both, count as Temporary)
								Temporary			Permanent								Total		Number on
																			Patients		APRV
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10
	11
	12
	13
	14
	15
	16
	17
	18
	19
	20
	21
	22
	23
	24
	25
	26
	27
	28
	29
	30
	31
		*Totals
								Temporary CL-			Permanent CL-
					Patient-days										Urinary catheter-days					Ventilator-days
								days			days
		**Conditionally required according to the events indicated in Plan.
		Label			_____________				_____________			_____________				_____________				_____________
		Data			_____________				_____________			_____________				_____________				_____________

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 hours 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 57.117, Rev 1, v7.1