Forms

NHSN Device-Associated Module Denominator Forms

• CDC 57.116
  Use for collection of denominators for central lines, urinary catheters, or ventilators on Neonatal Intensive Care Units. Data from this form may be entered starting at the end of the month of surveillance as summary data in NHSN.
• CDC 57.117
  Use for collection of denominators for central lines, urinary catheters, or ventilators on Specialty Care Units (not Neonatal Intensive Care Units). Check NHSN location description for specialty care units versus Intensive Care Units prior to using this form. Data from this form may be entered starting at the end of the month of surveillance as summary data in NHSN.
• CDC 57.118
  Use for collection of denominators for central lines, urinary catheters, or ventilators on Intensive Care Units and other locations such as Wards(not Neonatal Intensive Care Units or Specialty Care Areas). Data from this form may be entered starting at the end of the month of surveillance as summary data in NHSN.

NHSN Device Associated Module Numerator Forms

• CDC 57.108
  Use for collection of numerators for blood stream infections. Data from this form may be entered as it occurs during the month of surveillance as event data in NHSN.
• CDC 57.114
  Use for collection of numerators for urinary tract infections. Data from this form may be entered as it occurs during the month of surveillance as event data in NHSN.

NHSN Procedure Associated Module Denominator Form

• CDC 57.121
  Use for collection of denominators for surgical procedures. Data from this form may be entered daily during the month of surveillance as procedure data in NHSN.

NHSN Procedure Associated Module Numerator Form

• CDC 57.120
  Use for collection of numerators for surgical site infections. Data from this form may be entered as it occurs during the month of surveillance as event data in NHSN.

ADPH Forms

• Facility Contact Information
  Use this form to report contact information to the Alabama Department of Public Health (ADPH) for the National Healthcare Safety Network (NHSN) Facility Administrator (FA) and NHSN Users at each Healthcare Facility.