Fillable Printable 57.118 Denominatoricu Blank
Fillable Printable 57.118 Denominatoricu Blank
57.118 Denominatoricu Blank
Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2019
www.cdc.gov/nhsn
Denominators for Intensive Care Unit (ICU)/Other Locations
(not NICU or SCA)
Page 1 of 1
*required for saving
Facility ID:*Location Code: *Month:*Year:
Date
*Number
of Patients
**Number of patient s
with 1 or more central
lines
**Number of patient s
with a urinary
catheter
**Number of patient s on a
ventilator
Number of
Episodes of
Mechanical
Ventilation
Total
Patients
Number on
APRV
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*Totals
Patient-daysCentral-line daysUrinary catheter-daysVentilator-days
Episodes of
Mechanical
Ventilation
**Conditionally required acc ording to the event s i ndicated in Plan.
Label_________________________________________________________________
Data_________________________________________________________________
Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is
collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or releasedwithout the
consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).
Public reporting burden of this collection of information is estimated to average 5 hours per response, including the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send commentsregarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74,
Atlanta, GA 30333, ATTN: PRA (0920-0666).
CDC 57.118, Rev.2, v8.3
