National Healthcare Safety Network (NHSN)

NHSN provides forms which can be used for routine data collection. These forms are listed below and can be printed and used within your facility. The PDF versions printed and used as-is and the PowerPoint versions are provided for those facilities that wish to modify and customize the forms to meet their specific needs.

NHSN Data Collection Forms

Form Name	PDF*	PowerPoint**
Enrollment Forms
Facility Contact Information	Print Only 67KB/2 pages	Edit/Customize 105KB/2 pages
Hospital Survey only used if enrolling facility is a hospital	Print Only 90KB/2 pages	Edit/Customize 107KB/2 pages
Outpatient Dialysis Center Practices Survey only used if enrolling facility is an outpatient dialysis center	Print Only 165KB/4 pages	Edit/Customize 125KB/4 pages
Patient Safety Forms
Dialysis Incident (DI)	Print Only 284KB/2 pages	Edit/Customize 136KB/2 pages
Group Contact Information	Print Only 39KB/1 page	Edit/Customize 93KB/1 page
Monthly Reporting Plan	Print Only 27KB/2 pages	Edit/Customize 102KB/2 pages
Patient Data	Print Only 65KB/1 page	Edit/Customize 81KB/1 page
Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data	Print Only 122KB/1 page	Edit/Customize 144KB/1 page
Antimicrobial Use and Resistance (AUR) - Pharmacy Data	Print Only 91KB/1 page	Edit/Customize 132KB/1 page
Denominators for Intensive Care Unit (ICU)/Other Locations	Print Only 85KB/1 page	Edit/Customize 135KB/1 page
Denominators for Specialty Care Area (SCA)	Print Only 95KB/1 page	Edit/Customize 144KB/1 page
Denominators for Neonatal Intensive Care Unit (NICU)	Print Only 217KB/1 page	Edit/Customize 259KB/1 page
Denominator for Procedure	Print Only 55KB/1 page	Edit/Customize 102KB/ page
Denominator for Custom Procedure	Print Only 43KB/ page	Edit/Customize 84KB/1 page
Denominators for Outpatient Dialysis	Print Only 43KB/1 page	Edit/Customize 87KB/1 page
Updated Patient Safety Forms NOTE: The following Event forms have been revised to include additional data collection fields. These fields are not yet available for entry into NHSN.
Custom Event	Print Only 202KB/3 pages	Edit/Customize 141KB/3 pages
Primary Bloodstream Infection (BSI)	Print Only 83KB/3 pages	Edit/Customize 139KB/3 pages
Pneumonia (PNEU)	Print Only 193KB/3 pages	Edit/Customize 144KB/3 pages
Urinary Tract Infection (UTI)	Print Only 104KB/3 pages	Edit/Customize 142KB/3 pages
Surgical Site Infection (SSI)	Print Only 103KB/3 pages	Edit/Customize 141KB/3 pages
High Risk Inpatient Influenza Vaccination Monthly Monitoring Forms
Method A	Print Only       44KB/1 page	Edit/Customize       65KB/1 page
Method B	Print Only       36KB/1 page	Edit/Customize       60KB/1 page
Method B Form - Part 1	Print Only       71KB/2 pages	Edit/Customize       70KB/2 pages
Method B Form - Part 2	Print Only       60KB/2 pages	Edit/Customize       72KB/2 pages
Standing Orders Form - Optional	Print Only       53KB/3 pages	Edit/Customize       87KB/3 pages
Central Line Insertion Practices (CLIP) Adherence Monitoring
CLIP Adherence Monitoring form 57.125 Updated August 2008	Print Only       100KB/2 pages	Edit/Customize       75KB/2 pages

* Note: Reading PDF documents requires Adobe Acrobat Reader, which may be downloaded free from: http://www.adobe.com/products/acrobat/readermain.html.

** Note: To view and edit these documents you will need Microsoft Powerpoint 2002 or newer.

Please note: Some of these publications are available for download only as *.pdf files. These files require Adobe Acrobat Reader in order to be viewed. Please review the information on downloading and using Acrobat Reader software.

Microsoft PowerPoint
Description: Microsoft PowerPoint is a program for creating and viewing presentations and slide shows.
File extensions: .ppt Viewing: If you do not already have PowerPoint, you can download PowerPoint Viewer for free*.

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