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
Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data Modified 270000 810000 0 Form 57.75P
Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 216000 432000 0 Form 57.75Q
Central Line Insertion Practices Adherence Monitoring Form Modified 600000 100000 0 Form 57.75JJ
Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA) Modified 108000 540000 0 Form 57.75L
Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 216000 0 Form 57.75J
Denominators for Outpatient Dialysis Modified 2025 169 0 Form 57.75M
Denominators for Procedure Modified 3240000 432000 0 Form 57.75O
Denominators for Specialty Care Area (SCA) Modified 54000 270000 0 Form 57.75K
Dialysis Event Modified 45000 11250 0 Form 57.75E
Dialysis Survey Modified 225 225 0 Form 57.75BB
Exposure to Blood and Body Fluids Modified 30000 30000 0 Form 57.75V
Facility Contact Information Modified 6000 1000 0 Form 57.75R
Group Contact Information Modified 6000 500 0 Form 57.75U
Healthcare Personnel Safety Component Facility Survey Modified 600 4800 0 Form 57.75Za
Healthcare Personnel Safety Reporting Plan Modified 5400 900 0 Form 57.75B
Healthcare Worker Demographic Data Modified 120000 40000 0 Form 57.75X
Healthcare Worker Influenza Antiviral Medication Administration Modified 30000 5000 0 Form 57.75GG
Healthcare Worker Influenza Vaccination Modified 300000 50000 0 Form 57.75FF
Healthcare Worker Post-Exposure Prophylaxis Modified 6000 1500 0 Form 57.75W
Healthcare Worker Survey Modified 60000 10000 0 Form 57.75AA
Healthcare Worker Vaccination History Modified 180000 30000 0 Form 57.75Y
Hemovigilance Adverse Reaction New 60000 10000 0 Form 57.304
Hemovigilance Incident New 36000 6000 0 Form 57.305
Hemovigilance Module Annual Survey New 500 1000 0 Form 57.300
Hemovigilance Module Blood Product Incident Reporting - Summary Data New 6000 12000 0 Form 57.302
Hemovigilance Module Monthly Reporting Denominators New 6000 3000 0 Form 57.303
Hemovigilance Module Monthly Reporting Plan New 6000 200 0 Form 57.301
High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B Modified 500000 41667 0 Form 57.75SS
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 B Modified 10000 40000 0 Form 57.75RR
High Risk Inpatient Influenza Vaccination Numerator Data Form - Method B Modified 500000 83333 0 Form 57.75QQ
Implementation of Engineering (safety devices) Controls for Sharps Injury Prevention Removed 0 0 0 Form 57.75Z
Laboratory Identified MDRO Event Modified 1440000 720000 0 Form 57.75NN
Laboratory Testing Modified 60000 15000 0 Form 57.75KK
Laboratory-identified MDRO Event Summary Form Removed 0 0 0 Form 57.75TT
List of Blood Isolates Modified 6000 6000 0 Form 57.75CC
MDRO Infection Event Modified 432000 216000 0 Form 57.75MM
Manual Categorization of Positive Blood Cultures Modified 6000 6000 0 Form 57.75DD
Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form Modified 144000 24000 0 Form 57.75LL
NHSN Registration Form Modified 6000 500 0 Form 57.75OO
Patient Safety Component Annual Facility Survey Modified 6000 3000 0 Form 57.75S
Patient Safety Monthly Reporting Plan Modified 54000 31500 162000 Form 57.75A
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
Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel Modified 600 100 0 Form 57.75II
Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Modified 600 100 0 Form 57.75HH
Primary Bloodstream Infection (BSI) Modified 216000 108000 0 Form 57.75D
Surgical Site Infection (SSI) Modified 162000 81000 0 Form 57.75N
Urinary Tract Infection (UTI) Modified 162000 81000 0 Form 57.75H
Total burden requested under this ICR: 9620950 5172244 162000  
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