Data Collection Forms
NHSN provides forms which can be used for routine data collection. These forms are listed below and can be printed and used within your facility. The PDF versions printed and used as-is and the PowerPoint versions are provided for those facilities that wish to modify and customize the forms to meet their specific needs.
Enrollment
| Form Types | Form # Name (PDF for print only) | PowerPoint | Form instructions |
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Patient Safety Component
| Enrollment / General | |||
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| Form Types | Form # Name (PDF for print only) | PowerPoint | Form instructions |
| Survey |
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| General |
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| Device-associated (DA) Module | |||
| Event Types | Form # Name (PDF for print only) | PowerPoint | Form instructions |
| Dialysis |
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• CLABSI • VAP • CAUTI |
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| • CLIP |
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| • VAP • PPP |
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| Procedure-associated (PA) Module | |||
| • SSI • PPP |
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| Medication-associated (MA) Module | |||
| • AUR |
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| MDRO / CDAD Module | |||
| • MDRO |
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| See additional MDRO forms | 57.108 Primary Bloodstream Infection (BSI) |
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| High Risk Inpatient Influenza Vaccination (HRIIV) Module | |||
| • HRIIV |
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Please note: Some of these publications are available for download only as *.pdf files. These files require Adobe Acrobat Reader in order to be viewed. Please review the information on downloading and using Acrobat Reader software. 
Please note: PowerPoint is a program for creating and viewing presentations and slide shows. These files (.ppt) require Microsoft PowerPoint in order to be viewed. If you do not already have PowerPoint, you can download PowerPoint Viewer for free*.
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Contact NHSN:
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Centers for Disease Control and Prevention
National Healthcare Safety Network
MS-A24
1600 Clifton Rd
Atlanta, GA 30333 - nhsn@cdc.gov
