Patient 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.
Survey Forms
- 57.103 Patient Safety Component—Annual Facility Survey [PDF - 70 KB] January 2012
only used if enrolling facility is a hospital.
- Customizable form [DOC - 37 KB] January 2012
- Form Instructions [PDF - 193 KB] January 2012
- 57.150 Patient Safety Component—Annual Facility Survey for LTAC [PDF - 73 KB] January 2012
- Customizable form [DOC - 42 KB] January 2012
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57.151 Patient Safety Component—Annual Facility Survey for IRF [PDF - 81 KB] January 2012
- Customizable form [DOC - 37 KB] January 2012
General Forms
- 57.106 Patient Safety Monthly Reporting Plan [PDF - 56 KB] January 2012
- Customizable form [DOC - 36 KB] January 2012
- Form Instructions [PDF - 36 KB] January 2012
- 57.115 Custom Event [PDF - 677 KB] January 2012
- Customizable form [DOC - 150 KB] January 2012
Summary Denominator Monthly Forms
- 57.116 Denominators for Neonatal Intensive Care Unit (NICU) [PDF - 84 KB] January 2012
- Customizable form [DOC - 39 KB] January 2012
- Form Instructions [PDF - 72 KB] January 2012
- 57.117 Denominators for Specialty Care Area (SCA) [PDF - 42 KB] January 2012
- Customizable form [DOC - 141 KB] January 2012
- Form instructions [PDF - 50 KB] January 2012
- 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA) [PDF - 40 KB] January 2012
- Customizable form [DOC - 31 KB] January 2012
- Form Instructions [PDF - 55 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
Device-associated (DA) Module
Dialysis Forms
Outpatient Dialysis Facility Enrollment and Annual Survey
- 57.104 Outpatient Dialysis Center Practices Survey [PDF - 81 KB] January 2012 only used if enrolling facility is an outpatient dialysis center.
- Customizable form [DOC - 43 KB] January 2012
Event Form
- 57.109 Dialysis Event [PDF - 106 KB] January 2012
- Customizable form [DOC - 50 KB] January 2012
- Dialysis Event Form Instructions - [PDF - 112 KB] February 2012
Patient Census Form
- 57.119 Denominators for Outpatient Dialysis
Census Form – completed once per month [PDF - 33 KB] January 2012
- Customizable form [DOC - 33 KB] January 2012
- Denominators for Outpatient Dialysis Form Instructions [PDF - 67 KB] February 2012
Other Reporting Resources
- How to Create and Read an NHSN Report for CMS ERSD QIP [PDF - 379 KB ] April 2012
- Quick Reference for Monthly Dialysis Event Surveillance [PDF - 325 KB]
- 57.110 Dialysis Event Log [PDF - 70 KB] June 2011 (optional)
- Customizable form [PPT - 298 KB] June 2011
CLABSI Form
- 57.108 Primary Bloodstream Infection (BSI) [PDF - 50 KB] January 2012
- Customizable form [DOC - 50 KB] January 2012
- Form Instructions [PDF - 78 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
CLIP Form
- 57.125 Central Line Insertion Practices Adherence Monitoring [PDF - 54 KB] January 2012
- Customizable form [DOC - 38 KB] January 2012
- Form Instructions [PDF - 71 KB] January 2012
CAUTI Form
- 57.114 Urinary Tract infection (UTI) [PDF - 100 KB] January 2012
- Customizable form [DOC - 51 KB] January 2012
- Form Instructions [PDF - 59 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
VAP Form
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57.111 Pneumonia (PNEU) [PDF - 104 KB] January 2012
- Customizable form [DOC - 52 KB] January 2012
- Form Instructions [PDF - 65 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
Procedure-associated (PA) Module
SSI and Denominator for Procedure Forms
- 57.120 Surgical Site Infection (SSI) [PDF - 93 KB] January 2012
- Customizable form [DOC - 55 KB] January 2012
- Form Instructions [PDF - 72 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
- 57.121 Denominator for Procedure [PDF - 42 KB] January 2012
- Customizable form [DOC - 31 KB] January 2012
- Form Instructions [PDF - 72 KB] January 2012
- 57.122 Denominator for Custom Procedure [PDF - 42 KB] June 2011
- Customizable form [PPT - 91 KB] Janurary 2011
MDRO / CDI Module
- 57.127 MDRO and CDI Prevention Process and Outcome
Measures Monthly Reporting [PDF - 42 KB] January 2012
- Customizable form [DOC - 43 KB] January 2012
- Form Instructions [PDF - 114 KB] January 2012
- 57.126 MDRO or CDI Infection Event [PDF - 54 KB] January 2012
- Customizable form [DOC - 57 KB] January 2012
- Form Instructions [PDF - 76 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
- 57.128 Laboratory-identified MDRO or CDI Event [PDF - 47 KB] January 2012
- Customizable form [DOC - 31 KB] January 2012
- Form Instructions [PDF - 69 KB] January 2012
- 57.108 Primary Bloodstream Infection (BSI) [PDF - 50 KB] January 2012
- Customizable form [PPT - 139 KB] January 2012
- Form Instructions [PDF - 78 KB] January 2012
- also see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
- 57.111 Pneumonia (PNEU) [PDF - 104 KB] January 2012
- Customizable form [DOC - 52 KB] January 2012
- Form Instructions [PDF - 65 KB] January 2012
- aalso see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
- 57.114 Urinary Tract infection (UTI) [PDF - 100 KB] January 2012
- Customizable form [DOC - 51 KB] January 2012
- Form Instructions [PDF - 59 KB] January 2012
- aalso see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
- 57.120 Surgical Site Infection (SSI) [PDF - 93 KB] January 2012
- Customizable form [DOC - 141 KB] January 2012
- Form Instructions [PDF - 68 KB] January 2012
- aalso see: Instructions for Pathogen Information for HAIs [PDF - 78 KB] June 2011
Vaccination Module
Summary Method
- 57.130 Vaccination Monthly Monitoring Form-Summary Method [PDF - 43 KB] January 2012
- Customizable form [DOC - 33 KB] January 2012
- Form Instructions [PDF - 84 KB] January 2012
Patient-Level Method
- 57.131 Vaccination Monthly Monitoring Form—Patient-Level Method [PDF - 43 KB] January 2012
- Customizable form [DOC - 32 KB] January 2012
- Form Instructions [PDF - 80 KB] January 2012
- 57.133 Patient Vaccination [PDF - 52 KB] January 2012
- Customizable form [DOC - 39 KB] January 2012
- Form Instructions [PDF - 89 KB] January 2012
- 57.134 Influenza Vaccination Standing Orders [PDF - 95 KB] January 2012
- Customizable form [DOC - 30 KB] January 2012
- Form Instructions [PDF - 69 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
