View Information Collection (IC)

View Information Collection (IC)

IC Title:	57.203 Healthcare Personnel Safety Reporting Plan	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-WORD			57.203_HCPSafetyPlan_BLANK.docx		Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	100	0	-5,300	0	0	5,400
Annual IC Time Burden (Hours)	150	0	-750	0	0	900
Annual IC Cost Burden (Dollars)	5,954	0	5,954	0	0	0

Documents for IC

Title	Document	Date Uploaded
Att G.7 HPSC	7. Healthcare Personnel Safety Component (IC#s 3, 9, 16, 34, 35, 36, 38).pdf	10/15/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.