Fillable Printable 57.107 Patient Data Blank
Fillable Printable 57.107 Patient Data Blank
57.107 Patient Data Blank
OMB No. 0920-0666
Exp. Date: 09-30-2012
PatientData
Birthweight(grams):
*DateofBirth:*Gender:FM
Comments
CustomFields
Label
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Label
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AssuranceofConfidentiality:Theinformationobtainedinthissurveillancesystemthatwouldpermitidentificationofanyindividualorinstitutioniscollectedwithaguaranteethatitwillbeheldinstrict
confidence,willbeusedonlyforthepurposesstated,andwillnototherwisebedisclosedorreleasedwithouttheconsentoftheindividual,ortheinstitutioninaccordancewithSections304,306and308(d)of
thePublicHealthServiceAct(42USC242b,242k,and242m(d)).
Publicreportingburdenofthiscollectionofinformationisestimatedtoaverage0minutesperresponse,includingthetimeforreviewinginstructions,searchingexistingdatasources,gatheringand
maintainingthedataneeded,andcompletingandreviewingthecollectionofinformation.Anagencymaynotconductorsponsor,andapersonisnotrequiredtorespondtoacollectionofinformationunless
itdisplaysacurrentlyvalidOMBcontrolnumber.Sendcommentsregardingthisburdenestimateoranyotheraspectofthiscollectionofinformation,includingsuggestionsforreducingthisburdentoCDC,
ReportsClearanceOfficer,1600CliftonRd.,MSD-74,Atlanta,GA30333ATTN:PRA(0920-0666).
CDC57.107Rev.1
SocialSecurity#:*PatientID:
Race(checkallthatapply):
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AmericanIndianorAlaskaNative
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Asian
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BlackorAfricanAmerican
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NativeHawaiianorOtherPacific Islander
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White
Ethnicity:
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Hispanic orLatino
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NotHispanic orNotLatino
PatientName,Last:First:Middle:
SecondaryID:
*
indicatesarequiredfield
FacilityID:
