Form Cdc 57.503 - Denominators For Dialysis Event Surveillance

Form Approved

OMB No. 0920-0666

Exp. Date: 11/30/2019

Denominators for Dialysis Event Surveillance

Census Form – completed once per month

Complete this form as indicated by the Dialysis Event Protocol:

Instructions for this form are available at:

*required for saving

Page 1 of 1

Reporting to “Outpatient Hemodialysis Clinic” Location:

Record the number of outpatients who received hemodialysis at your center on the first two working days of the

month, including transient patients. A patient must be physically present for hemodialysis on one of these days to be

counted on this form (e.g., exclude patients who are hospitalized). Record each patient only once. If a patient has

more than one vascular access, record the access type with highest risk for infection (per the protocol), even if that

access is not used for dialysis or is abandoned.

Facility ID #:

*Location Code:

*Month:

*Year:

*Number of

*Vascular Access Type

Hemodialysis

Outpatients

Number of these Fistula

Fistula

Patients who undergo

Buttonhole Cannulation

Graft

Tunneled central line

Nontunneled central line

Other vascular access device

(e.g., catheter-graft hybrid, port)

*Number of these patients

*Total patients

for whom dialyzers are

(sum of all patients listed above)

reused

Custom Fields:

Label

______________

______________

______________

______________

______________

Data

______________

______________

______________

______________

______________

Comments:

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 10 minutes 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 57.503 Rev 8, v8.6