Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Agreement to Participate and Consent Modified 6000 1500 0 Form 57.75T Agreement to Participate and Consent
Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data Modified 270000 810000 0 Form 57.75P Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data
Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 216000 432000 0 Form 57.75Q Antimicrobia Use and Resistence (AUR) - Pharmacy Data
Central Line Insertion Practices Adherence Monitoring Form Modified 600000 100000 0 Form 57.75JJ Central Line Insertion Practices Adherence Monitoring Form
Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA) Modified 108000 540000 0 Form 57.75L Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA)
Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 216000 0 Form 57.75J Demonination for Neonatal Intensive Care Unit (NICU)
Denominators for Outpatient Dialysis Modified 2025 169 0 Form 57.75M Denominators for Outpatient Dialysis
Denominators for Procedure Modified 3240000 432000 0 Form 57.75O Denominators for Procedure
Denominators for Specialty Care Area (SCA) Modified 54000 270000 0 Form 57.75K Denominators for Specialty Care Area (SCA)
Dialysis Event Modified 45000 11250 0 Form 57.75E Dialysis Event
Dialysis Survey Modified 225 225 0 Form 57.75BB Dialysis Survey
Exposure to Blood and Body Fluids Modified 30000 30000 0 Form 57.75V Exposure to Blood and Body Fluids
Facility Contact Information Modified 6000 1000 0 Form 57.75R Facility Contact Information
Group Contact Information Modified 6000 500 0 Form 57.75U Group Contact Information
Healthcare Personnel Safety Component Facility Survey Modified 600 4800 0 Form 57.75Za Healthcare Personnel Safety Component Facility Survey
Healthcare Personnel Safety Reporting Plan Modified 5400 900 0 Form 57.75B Healthcare Personnel Safety Reporting Plan
Healthcare Worker Demographic Data Modified 120000 40000 0 Form 57.75X Healthcare Worker Demographic Data
Healthcare Worker Influenza Antiviral Medication Administration Modified 30000 5000 0 Form 57.75GG Healthcare Worker Influenza Antiviral Medication Administration
Healthcare Worker Influenza Vaccination Modified 300000 50000 0 Form 57.75FF Healthcare Worker Influenza Vaccination
Healthcare Worker Post-Exposure Prophylaxis Modified 6000 1500 0 Form 57.75W Healthcare Worker Post-Exposure Prophylaxis
Healthcare Worker Survey Modified 60000 10000 0 Form 57.75AA Healthcare Worker Survey
Healthcare Worker Vaccination History Modified 180000 30000 0 Form 57.75Y Healthcare Worker Vaccination History
High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B Modified 500000 41667 0 Form 57.75SS High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B
High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A Modified 30000 480000 0 Form 57.75PP High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A
High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B Modified 10000 40000 0 Form 57.75RR High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B
High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B Modified 500000 83333 0 Form 57.75QQ High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B
Implementation of Engineering (safety devices) Controls for Sharps Injury Prevention Modified 600 300 0 Form 57.75Z Implementation of Engineering (safety devices) Controls for Sharps Injury Prevention
Laboratory Identified MDRO Event Modified 1440000 720000 0 Form 57.75NN Laboratory Identified MDRO Event
Laboratory Testing Modified 60000 15000 0 Form 57.75KK Laboratory Testing
Laboratory-identified MDRO Event Summary Form Modified 4500 4500 0 Form 57.75TT Laboratory-identified MDRO Event Summary Form
List of Blood Isolates Modified 6000 6000 0 Form 57.75CC List of Blood Isolates
MDRO Infection Event Modified 432000 216000 0 Form 57.75MM MDRO Infection Event
Manual Categorization of Positive Blood Cultures Modified 6000 6000 0 Form 57.75DD Manual Categorization of Positive Cultures
Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form Modified 144000 24000 0 Form 57.75LL Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form
NHSN Registration Form Modified 6000 500 0 Form 57.75OO NHSN Registration Form
Patient Safety Component Annual Facility Survey Modified 6000 3000 0 Form 57.75S Patient Safety Component Annual Facility Survey
Patient Safety Monthly Reporting Plan Modified 54000 31500 162000 Form 57.75A A_PSPlan.ppt
Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 432000 216000 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 Modified 600 100 0 Form 57.75II Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel
Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Modified 600 100 0 Form 57.75HH Preseason Survey on Influenza Vaccination Programs for Healthcare Personnel
Primary Bloodstream Infection (BSI) Modified 216000 108000 0 Form 57.75D Primary Bloodstream Infection (BSI)
Surgical Site Infection (SSI) Modified 162000 81000 0 Form 57.75N Surgical Site Infection (SSI)
Urinary Tract Infection (UTI) Modified 162000 81000 0 Form 57.75H Urinary Tract Infection (UTI)
Total burden requested under this ICR: 9511550 5144844 162000  
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