Fillable Printable 57.139 Mdro Monthly Reporting Ltcf Blank

57.139 Mdro Monthly Reporting Ltcf Blank

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

MDRO and CDI LabID Event Re p orti n g

Monthly Summary Data for LTCF

Page 1 of 1

*required for saving**conditionally required based upon monitoring sel ec tion in Monthly Reporting Plan

Facility ID #: ______________*Month: ____________ *Year: _________ _*Location Code: ____________

*Resident Days: _____ *Resident Admissions:______**Number of Adm i ssions on C. diff Treatment:_______

LabID Event Reporting

Specific

Organism Type

MRSAVRE

CephR-

Klebsiella

CRE-

E. coli

CRE-

Enterobacter

CRE-

Klebsiella

MDR-

Acinetobacter

C.difficile

LabID Event

(All specimens)

□□□□□□□□

Report No

Events

□□□□□□□□

Custom Fields (Optional)

Label_________________________________________________________________

Data_________________________________________________________________

Assurance of Confide nt iality: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 released without 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 10minutes 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 comments regarding this burden estimate

or any other aspect of this collection ofinformation, 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 57.139 rev 3, v.8.6