57.116 NICU Denominator
Denominators for Neonatal Intensive Care Unit (NICU)Page 1 of 4*Required for saving **Conditionally required according to the events indicated in PlanFacility ID:*Location Code:*Month:*Year:Birth Weight CategoriesDate: ≤750 g 751-1000 g1001-1500 g1501-2500 g >2500 gPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMV1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.21.22.23.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 240 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 H21-8, Atlanta, GA 30333, ATTN:? PRA (0920-0666).CDC 57.116(Front), Rev 2 v9.2 Continued >>>Page 2 of 4*Required for saving **Conditionally required according to the events indicated in PlanBirth Weight Categories (continued)Date: ≤750 g751-1000 g1001-1500 g1501-2500 g >2500 gPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMVPt***CL**VNTUrCEMV24.25.26.27.28.29.30.31.*TotalPt=number of infants CL=number of infants with 1 or more central lines, including umbilical catheter VNT=number of infants on a ventilator UrC=number of infants with a urinary catheter EMV= Episodes of mechanical ventilation Label___________________________________________________________________________Data___________________________________________________________________________PedVAE Optional Denominators Neonatal Intensive Care Unit (NICU)Page 3 of 4*Required for Saving **Conditionally required according to the events indicated in the planFacility ID :*Location Code:*Month:*Year:Gestational Age CategoriesDate: Extremely preterm(<28 weeks) Very preterm(28 to <32 weeks)Moderate to late preterm (32 to <37 weeks) Term (≥37 weeks)PTVNTEMVPTVNTEMVPTVNTEMVPTVNTEMV2.3.4.5.6.7.8.9.10.11.12.13.1415.16.17.18.19.20.21.22.23.24.25.Page 4 of 4*Required for saving **Conditionally required according to the events indicated in PlanGestational Age Categories (continued)Date: Extremely preterm(<28 weeks) Very preterm(28 to <32 weeks)Moderate to late preterm (32 to <37 weeks) Term (≥37 weeks)PTVNTEMVPTVNTEMVPTVNTEMVPTVNTEMV26.27.28.29.30.31.*TotalPt=number of infants VNT=number of infants on a ventilator EMV= Episodes of mechanical ventilation Label___________________________________________________________________________Data___________________________________________________________________________ ................
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