HAI Hospital Survey Tool


This survey is to provide the Florida Department of Health (FDOH) Healthcare-Associated Infections (HAI) Program with some basic information about Florida hospitals and their plans for electronic data reporting (EDR) to the National Healthcare Safety Network (NHSN). The information will be used to understand the facility’s current readiness and interest in HAI Electronic Data Reporting. The information will also provide the HAI Program with some background information that will be helpful when trying to assist your facility with any NHSN questions

General Information

1. Hospital name:


2. Address


3. County


4. Is your facility interested in assistance with electronic data reporting from the Florida HAI Program?



NOTE: if you have answered “No” to question four you do not need to answer any more questions.

5. Who would be the best person to contact if the FDOH has questions concerning the general use of NHSN (i.e. regular reporting, surveillance, etc.) at your facility?


6. Name


7. Phone Number


8. Email Address


9.Does your facility have multiple locations?



10. Which collaborative group are you participating in with the FDOH? (Please mark all that apply)



11. Is your facility considering reporting manually on any of the following in the NSHN system? (Please mark all that apply and what type data entry will be used.)






12. Is your facility considering reporting using CDA importing on any of the following in the NSHN system?






Facility Standards and Directions

13. Does your facility have an Electronic Health Record (EHR) system? If so, please indicate the Product name for your EHR system. (Example of a few EHR systems: Guardian System, Safety Surveillance, Theradoc):




14. Does facility’s EHR system have any of the following capabilities/modules? (Please mark all that apply)







15.Does the currently EHR system have HL7 interface capabilities?




16. Does your current Laboratory Information Management System (LIMS) system capable of Electronic Laboratory Reporting (ELR)?




17. Is your currently EHR system capable of producing the XML files needed for importing data to NHSN?




18. Is your facility planning to upgrade the ERH system with a system that will have the capability to create the XML files for importing into NHSN within the next 12 months?




Submit Data to NHSN

19. Does your facility currently submit any data to NHSN?



20. How do you currently submit data to NHSN? (Please mark all that apply)





21. Who is responsible in your facility for identifying cases that need to be reported to NHSN? (Please mark all that apply)





22. Who is responsible in your facility for reporting cases to NHSN? (Please mark all that apply)