Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is.

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Presentation transcript:

Assurance of Confidentiality: The 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 30 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 ( ). CDC 57.75Z (Front) Rev. 1, Effective date XX/XX/200X OMB No Exp. Date: Implementation of Engineering Controls (Safety Devices) for Sharps Injury Prevention Facility ID # :_______________ Year of Survey: ______ Device TypeYour Code Safety Feature Manufacturer and Model Device ImplementationDevice Discontinuation QtrYrScope of Use QtrYrReason Arterial blood collection device Hypodermic needle attached to syringe Unattached hypodermic needle Prefilled cartridge syringe needle IV-delivery system IV catheter - peripheral IV catheter – central line Huber needle

Device TypeYour Code Safety Feature Manufacturer and Model Device ImplementationDevice Discontinuation QtrYrScope of Use QtrYrReason Winged-steel (Butterfly™- type) needle Vacuum tube collection holder with needle Blood culture adapter Lancet Hemodialysis needle Dental aspirating syringe/needle Suture needle Scalpel Capillary tubes Blood collection tubes CDC 57.75Z (Back) Ver. 1.0, Rev. 01/01/2005

Device TypeYour Code Safety Feature Manufacturer and Model Device ImplementationDevice Discontinuation QtrYrScope of Use QtrYrReason Catheter securement device CDC 57.75Z (Back) Ver. 1.0, Rev. 01/01/2005