Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Agreement to Participate and Consent New 1500 375 0 Form 57.75T Agreement to Participate and Consent
Antimicrobia Use and Resistence (AUR) - Pharmacy Data New 54000 108000 0 Form 57.75Q Antimicrobia Use and Resistence (AUR) - Pharmacy Data
Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data New 67500 202500 0 Form 57.75P Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data
Central Line Insertion Practices Adherence Monitoring Form New 150000 12500 0 Form 57.75JJ Central Line Insertion Practices Adherence Monitoring Form
Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA) New 27000 135000 0 Form 57.75L Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)
Denominators for Neonatal Intensive Care Unit (NICU) New 13500 54000 0 Form 57.75J Demonination for Neonatal Intensive Care Unit (NICU)
Denominators for Outpatient Dialysis New 720 60 0 Form 57.75M Denominators for Outpatient Dialysis
Denominators for Procedure New 810000 108000 0 Form 57.75O Denominators for Procedure
Denominators for Specialty Care Area (SCA) New 13500 67500 0 Form 57.75K Denominators for Specialty Care Area (SCA)
Dialysis Event New 16000 4000 0 Form 57.75E Dialysis Event
Dialysis Survey New 80 80 0 Form 57.75BB Dialysis Survey
Exposure to Blood and Body Fluids New 7500 7500 0 Form 57.75V Exposure to Blood and Body Fluids
Facility Contact Information New 1500 250 0 Form 57.75R Facility Contact Information
Group Contact Information New 1500 125 0 Form 57.75U Group Contact Information
Healthcare Personnel Safety Component Facility Survey New 150 1200 0 Form 57.75Za Healthcare Personnel Safety Component Facility Survey
Healthcare Personnel Safety Reporting Plan New 1350 225 0 Form 57.75B Healthcare Personnel Safety Reporting Plan
Healthcare Worker Demographic Data New 30000 10000 0 Form 57.75X Healthcare Worker Demographic Data
Healthcare Worker Influenza Antiviral Medication Administration New 7500 1250 0 Form 57.75GG Healthcare Worker Influenza Antiviral Medication Administration
Healthcare Worker Influenza Vaccination New 75000 12500 0 Form 57.75FF Healthcare Worker Influenza Vaccination
Healthcare Worker Post-Exposure Prophylaxis New 1500 375 0 Form 57.75W Healthcare Worker Post-Exposure Prophylaxis
Healthcare Worker Survey New 15000 2500 0 Form 57.75AA Healthcare Worker Survey
Healthcare Worker Vaccination History New 45000 7500 0 Form 57.75Y Healthcare Worker Vaccination History
High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B New 125000 10417 0 Form 57.75SS High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B
High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A New 7500 120000 0 Form 57.75PP High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A
High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B New 2500 10000 0 Form 57.75RR High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B
High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B New 125000 20833 0 Form 57.75QQ High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B
Implementation of Engineering (safety devices) Controls for Sharps Injury Prevention New 150 75 0 Form 57.75Z Implementation of Engineering (safety devices) Controls for Sharps Injury Prevention
Laboratory Identified MDRO Event New 360000 180000 0 Form 57.75NN Laboratory Identified MDRO Event
Laboratory Testing New 15000 3750 0 Form 57.75KK Laboratory Testing
Laboratory-identified MDRO Event Summary Form New 4500 4500 0 Form 57.75TT Laboratory-identified MDRO Event Summary Form
List of Blood Isolates New 1500 1500 0 Form 57.75CC List of Blood Isolates
MDRO Infection Event New 108000 54000 0 Form 57.75MM MDRO Infection Event
Manual Categorization of Positive Blood Cultures New 1500 1500 0 Form 57.75DD Manual Categorization of Positive Cultures
Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form New 36000 6000 0 Form 57.75LL Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form
NHSN Registration Form New 1500 125 0 Form 57.75OO NHSN Registration Form
Patient Safety Component Annual Facility Survey New 1500 750 0 Form 57.75S Patient Safety Component Annual Facility Survey
Patient Safety Monthly Reporting Plan Modified 13500 7875 40500 Form 57.75A A_PSPlan.ppt
Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) New 108000 54000 0 Form and Instruction 57.75G, 57.75Ga, 57.75Gb Pneumonia (includes Any Patient Pneumonia Flow Diagram and Infant and Children Pneumonia Flow Diagram)
Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel New 150 25 0 Form 57.75II Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel
Preseason Survey on Influenza Vaccination Program for Healthcare Personnel New 150 25 0 Form 57.75HH Preseason Survey on Influenza Vaccination Programs for Healthcare Personnel
Primary Bloodstream Infection (BSI) New 54000 27000 0 Form 57.75D Primary Bloodstream Infection (BSI)
Surgical Site Infection (SSI) New 40500 20250 0 Form 57.75N Surgical Site Infection (SSI)
Urinary Tract Infection (UTI) New 40500 20250 0 Form 57.75H Urinary Tract Infection (UTI)
Total burden requested under this ICR: 2386250 1278315 40500  
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