Fillable Printable 57.504 Dialprocessmeasuresummary Blank

57.504 Dialprocessmeasuresummary Blank

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

www.cdc.gov/nhsn

Prevention Process Measures

Monthly Monitoring for Dialysis

Page 1 of 1

*required for saving

**Each process measure is conditionally required based upon monitoring selection in Monthly Reporting Plan

Facility ID #:_____________ *Month: _____________ *Year: ____________ *Location Code: ______________

Prevention Process Measures**

Observation Type # Successful Observations Total # Observations

1. Hand Hygiene

2. Hemodialysis Cat het er

Connection/Disconnection

3. Hemodialysis Catheter Exit Site Care

4. Arteriovenous Fistula and Graft

Cannulation/Decannulation

5. Dialysis Station Ro utine Disinfection

6. Injection Safety – Medication Preparation

7. Injection Safety – Medication Administration

Custom Fields

Label _____________ _____________ _____________ _____________ _____________

Data _____________ _____________ _____________ _____________ _____________

Comments

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 1.25 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 comments regarding 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 57.504 Rev 3, v8.5