Healthcare Personnel Safety Component
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.
General Forms
- 57.200 Healthcare Personnel Safety Component—Annual Facility Survey [PDF - 38 KB] January 2012
- Customizable form [DOC - 31 KB] January 2012
- 57.203 Healthcare Personnel Safety Monthly Reporting Plan [PDF - 42 KB] January 2012
- Customizable form [DOC - 28 KB] January 2012
- 57.204 Healthcare Worker Demographic Data [PDF - 53 KB] January 2012
- Customizable form [DOC - 37 KB] January 2012
Blood / Body Fluid [BBF] Exposures Forms
- 57.205 Exposure to Blood/Body Fluids [PDF - 104 KB] January 2012
- Customizable form [DOC - 52 KB] January 2012
- 57.206 Healthcare Worker Prophylaxis/Treatment BBF Postexposure Prophylaxis (PEP)[PDF - 54 KB] January 2012
- Customizable form [DOC - 34 KB] January 2012
- 57.207 Follow-up Laboratory Testing [PDF - 51 KB] January 2012
- Customizable form [DOC - 34 KB] January 2012
Influenza Vaccination Forms
- 57.209 Healthcare Worker Influenza Vaccination [PDF - 56 KB] January 2012
- Customizable form [DOC - 36 KB] January 2012
- 57.211 Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel [PDF - 51 KB] January 2012
- Customizable form [DOC - 33 KB] January 2012
- 57.212 Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel [PDF - 50 KB] January 2012
- Customizable form [DOC - 36 KB] January 2012
Influenza Exposure Management Forms
- 57.210 Healthcare Worker Prophylaxis/Treatment Influenza [PDF - 96 KB] January 2012
- Customizable form [DOC - 47 KB] January 2012
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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
