Form CDC 57.118 CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other Locatio

Form Approved

OMB No. 0920-0666

Exp. Date: xx/xx/20xx

www.cdc.gov/nhsn

Denominators for Intensive Care Unit (ICU)/Other Locations

(not NICU or SCA)

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*required for saving
Facility ID:			*Location Code:		*Month:			*Year:
Date	*Number of Patients		**Number of patients with 1 or more central lines			**Number of patients with a urinary catheter		**Number of patients on a ventilator				Number of Episodes of Mechanical Ventilation
								Total Patients		Number on APRV
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*Totals
	Patient-days		Central-line days			Urinary catheter-days		Ventilator-days				Episodes of Mechanical Ventilation
**Conditionally required according to the events indicated 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 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 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 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 57.118, Rev.2, v8.3