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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
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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