Form 57.105 Group Contact Information

* required for saving
NHSN Group Administrator

 *First Name:                                                       

 Middle Name:                                               

 *Last Name:                                                       

 *Group Name:                                                                                       

 *Group Administrator’s Mailing Address:                                                                        

                                        *City:                                                                
                                        *State:                         *Zip Code:                 -       
                                        *Telephone Number:  (     )                 -               
                                        Extension:                         

                                                *Email:                                                
                                                A valid email account is required.

*Type of Group (check one type and one subtype, if applicable)

                Healthcare system (a group of institutions organized under a common business entity)

                                Private, for profit

                                Private, not for profit

                Governmental

                                City/county

                                State

                                Federal

                        Quality Improvement/Patient Safety Organization
                (a group of facilities defined by the desire to improve healthcare quality and patient outcomes)

                        Other (describe):                                                                       

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 5 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 57.105  v6.4