Data Collection Forms
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 can be 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.
Enrollment / Facility Forms
- 57.101 Facility Contact Information [PDF - 42 KB] January 2012
- Customizable form [DOC - 37 KB] Feb 2012
- 57.105 Group Contact Information [PDF - 32 KB] January 2012
- Customizable form [DOC - 165 KB] Feb 2012
NHSN Forms by Components
Patient Safety Forms
Forms and instructions for Survey, Reports, Dialysis, CLABSI, VAP, CAUTI, CLIP, PPP, SSI, MDRO, CDI and Vaccination…
Healthcare Personnel Safety Forms
Forms for Survey, Blood / Body Fluid [BBF] Exposures, Influenza Vaccination, Influenza Exposure Management…
Biovigilance Forms
Forms and instructions for Survey, Incident, Adverse Reaction and Denominator…
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Contact NHSN:
-
Centers for Disease Control and Prevention
National Healthcare Safety Network
MS-A24
1600 Clifton Rd
Atlanta, GA 30333 - 800-CDC-INFO
(800-232-4636)
TTY: (888) 232-6348 - New Hours of Operation
8am-8pm ET/Monday-Friday
Closed Holidays - nhsn@cdc.gov
