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Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
57.100 NHSN Registration Form
Modified
6000
500
0
Form
57.100
NHSN Registration Form
57.101 Facility Contact Information
Modified
6000
1000
0
Form
57.101
Facility Contact Information
57.103 Patient Safety Component Annual Facility Survey
Modified
6000
3000
0
Other-WORD
57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey
Modified
5500
5500
0
Form
57.104
Patient Safety Component--Outpatient Dialysis Center Practices Survey
57.105 Group Contact Information
Modified
6000
500
0
Form
57.105
Group Contact Information
57.106 Patient Safety Monthly Reporting Plan
Modified
54000
31500
162000
Other-PDF
Form
57.106
Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)
Modified
216000
118800
0
Other-WORD
57.109 Dialysis Event
Modified
412500
110000
0
Other-WORD
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)
Modified
432000
230400
0
Form
57.111
Pneumonia (PNEU)
57.112 Streamlined Ventilator-Associated Pneumonia
New
864000
360000
0
Other-WORD
57.114 Urinary Tract Infection (UTI)
Modified
162000
86400
0
Other-WORD
57.116 Denominators for Neonatal Intensive Care Unit (NICU)
Modified
54000
162000
0
Other-WORD
57.117 Denominators for Specialty Care Area (SCA)
Modified
54000
270000
0
Form
57.117
Denominators for Specialty Care Area (SCA)
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)
Modified
108000
540000
0
Form
57.118
Denominator for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.119 Denominators for Outpatient Dialysis
Modified
66000
6600
0
Other-WORD
57.120 Surgical Site Infection (SSI)
Modified
216000
115200
0
Other-WORD
57.121 Denominators for Procedure
Modified
3240000
432000
0
Other-WORD
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data
Modified
72000
6000
0
Form
57.123
Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data
Modified
72000
6000
0
Form
57.124
Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specificaton Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form
Modified
100000
8333
0
Other-WORD
57.126 MDRO or CDI Infection Event
Modified
432000
230400
0
Other-WORD
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
Modified
144000
24000
0
Form
57.127
MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
57.128 Laboratory Identified or CDI MDRO Event
Modified
1440000
360000
0
Other-WORD
57.130 Vaccination Monthly Monitoring Form - Summary Method
Modified
30000
420000
0
Other-WORD
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method
Modified
10000
20000
0
Other-WORD
57.133 Patient Vaccination
Modified
500000
83333
0
Other-WORD
57.137 Long Term care Facility Component--Annual Facility Survey
Modified
250
104
0
Other-WORD
57.138 Laboratory-Identified MDRO or CDI Event for LTCF
Modified
2000
500
0
Other-WORD
57.139 MDRO and CDI Monthly Monitoring for LTCF
Modified
750
63
0
Other-WORD
57.140 Urinary Tract Infection (UTI) for LTCF
Modified
2250
1125
0
Other-WORD
57.141 Monthly Reporting Plan for LTCF
New
3000
250
0
Other-WORD
57.142 Denominators for LTCF Locations
New
3000
9000
0
Other-WORD
57.143 Prevention Process Measures Monthly Monitoring for LTCF
New
3000
250
0
Other-WORD
57.150 Patient Safety Component -- Annual Facility Survey for LTAC
New
400
200
0
Other-WORD
57.151 Patient Safety Component -- Annual Facility Survey for IRF
New
1000
417
0
Other-WORD
57.200 Healthcare Personnel Safety Component Facility Survey
Modified
6000
48000
0
Form
57.200
Healthcare Personnel Safety Component Annual Facility Survey
57.202 Healthcare Worker Survey
Modified
60000
10000
0
Form
57.202
HealthCare Worker Survey
57.203 Healthcare Personnel Safety Reporting Plan
Modified
5400
900
0
Form
57.203
Healthcare Personnel Safety Reporting Plan
57.204 Healthcare Worker Demographic Data
Modified
120000
40000
0
Form
57.204
Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids
Modified
30000
30000
0
Form
57.205
Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment
Modified
6000
1500
0
Other-WORD
57.207 Laboratory Testing
Modified
60000
15000
0
Form
57.207
Follow-up Laboratory Testing
57.208 Healthcare Worker Vaccination History
Modified
180000
30000
0
Form
57.208
Healthcare Worker Vaccination History
57.209 Healthcare Worker Influenza Vaccination
Modified
300000
50000
0
Form
57.209
Healthcare Worker Influenza Vaccinatuion
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza
Modified
30000
5000
0
Form
57.210
Healthcare Worker Prophylaxis/Treatment Influenza
57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel
Modified
600
100
0
Other-WORD
57.212 Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel
Modified
600
100
0
Form
57.212
Post-season Survey on Influenza Vaccination Programs for Health Personnel
57.213 Healthcare Personnel Influenza Vaccination Monthly Summary
Modified
36000
72000
0
Form
57.213
Healthcare Personnel Influenza Vaccination Monthly Summary
57.300 Hemovigilance Module Annual Facility Survey
Modified
500
1000
0
Other-WORD
57.301 Hemovigilance Module Monthly Reporting Plan
Modified
6000
200
0
Form
57.301
Hemovigilance Module Monthly Reporting Plan
57.302 Hemovigilance Module Monthly Incident Summary
Modified
6000
12000
0
Other-WORD
57.303 Hemovigilance Module Monthly Reporting Denominators
Modified
6000
3000
0
Form
57.303
Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction
Modified
60000
10000
0
Other-WORD
57.305 Hemovigilance Module Incident
Modified
36000
6000
0
Other-WORD
Total burden requested under this ICR:
9672750
3978175
162000
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