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:
*Number of
*Vascular Access Type
Number of these Fistula
Patients who undergo
Buttonhole Cannulation
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)
Custom Fields:
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


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Parent category: Medical