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Agenda
Reg Review
ICR
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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