№ files_lp_3_process_7_011265
Administrative public health surveillance reporting form documenting monthly HAI events, prevention process measures, and COVID-19 vaccination data for long-term care facilities under CDC oversight.
Year: Not specified
Month/Year: To be completed by facility
Facility ID: To be completed by facility
Document Type: Monthly reporting form
Subject: Healthcare Associated Infection (HAI) surveillance and prevention measures
Infection Types: UTI; Laboratory-identified Event (LabID Event)
Organism Data: Specific Organism Type; All Specimens
Prevention Measures: Hand Hygiene; Gown and Gloves Use
COVID-19 Module: Healthcare Personnel COVID-19 Vaccination Summary; Resident COVID-19 Vaccination Summary
Scope: Facility-wide Inpatient (FacWideIN)
Confidentiality Basis: Public Health Service Act Sections 304, 306 and 308(d) (42 USC 242b, 242k, 242m(d))
Responsible Authority: Centers for Disease Control and Prevention (CDC)
OMB Control Number: 0920-0666
Form Number: CDC 57.141 (Front), v7.0
Estimated Reporting Burden: 5 minutes per response
Submission Contact: CDC Project Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

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