Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100_NHSN Registration Form Modified 6000 500 0 Form CDC 57.100 NHSN Registration Form
57.101_Facility Contact Information Modified 6000 1000 0 Form CDC 57.101 Facility Contact Information
57.103_Patient Safety Component Annual Facility Survey Modified 6000 4000 0 Form CDC 57.103 Patient Safety Component --Annual Facility Survey
57.104_Patient Safety Component-- Outpatient Dialysis Center Practice Survey Modified 5500 5500 0 Form CDC 57.104 Patient Safety Component--Outpatient Dialysis Center Practices Survey
57.105_Group Contact Information Modified 6000 500 0 Form CDC 57.105 Group Contact Information
57.106_ Patient Safety Monthly Reporting Plan Modified 54000 31500 162000 Form CDC 57.106 Patient Safety Monthly Reporting Plan
57.108_Primary Bloodstream Infection (BSI) Modified 216000 115200 0 Form CDC 57.108 Primary Bloodstream Infection (BSI)
57.109_Dialysis Event Modified 37500 9375 0 Form CDC 57.109 Dialysis Event
57.111_Pneumonia (PNEU) Modified 432000 230400 0 Form CDC 57.111 Pneumonia (PNEU)
57.114_Urinary Tract Infection (UTI) Modified 162000 86400 0 Form CDC 57.114 Urinary Tract Infection (UTI)
57.116_Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 216000 0 Form CDC 57.116 Denominators for Neonatal Intensive Care Unit (NICU)
57.117_Denominators for Specialty Care Area (SCA) Modified 54000 270000 0 Form CDC 57.117 Denominators for Specialty Care Area (SCA)
57.118_Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA) Modified 108000 540000 0 Form CDC 57.118 Denominators for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.119_Denominators for Outpatient Dialysis Modified 6000 500 0 Form CDC 57.119 Denominators for Outpatient Dialysis
57.120_Surgical Site Infection (SSI) Modified 162000 86400 0 Form CDC 57.120 Surgical Site Infection (SSI)
57.121_Denominators for Procedure Modified 3240000 540000 0 Form CDC 57.121 Denominator for Procedure
57.123_Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data Modified 72000 6000 0 Form CDC 57.123 Antimicrobial Use and Resistance (AUR): Microbiology Laboratory Data Monthly Electronic Upload Specification Tables
57.124_Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 72000 6000 0 Form CDC 57.124 Antimicrobial Use and Resistance (AUR): Pharmacy Data Monthly Electronic Upload Specification Tables
57.125_Central Line Insertion Practices Adherence Monitoring Form Modified 600000 50000 0 Form CDC 57.125 Central Line Insertion Practices Adherence Monitoring
57.126_MDRO or CDI Infection Event Modified 432000 230400 0 Form CDC 57.126 MDRO or CDI Infection Event
57.127_Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form Modified 144000 24000 0 Form CDC 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
57.128_Laboratory Identified MDRO Event Modified 1440000 600000 0 Form CDC 57.128 Laboratory-identified MDRO or CDI Event
57.130_Vaccination Monthly Monitoring Form - Summary Method Modified 30000 420000 0 Form CDC 57.130 Vaccination Monthly Monitoring Form-- Summary Method
57.131_High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B Modified 10000 20000 0 Form CDC 57.131 Vaccination Monthly Monitoring Form-- Patient-Level Method
57.133_Patient Vaccination Modified 500000 83333 0 Form CDC 57.133 Patient Vaccination
57.137_Patient Safety Component --Annual Facility Survey for LTCF New 250 104 0 Form CDC 57.137 Patient Safety Component --Annual Facility Survey for LTCF
57.138 Laboratory-identified MDRO or CDI Event for LTCF New 2000 1000 0 Form 57.138 57.138_LabIDEvent_ LTCF_BLANK
57.139_MDRO or CDI Prevention Process Measures Monthly Monitoring for LTCF New 750 88 0 Form CDC 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF Modified 2250 1125 0 Form CDC 57.140 Urinary Tract Infection (UTI) for LTCF
57.200_Healthcare Personnel Safety Component Facility Survey Modified 6000 48000 0 Form CDC 57.200 Healthcare Personnel Safety Component Annual Facility Survey
57.202_Healthcare Worker Survey Modified 60000 10000 0 Form CDC 57.202 Healthcare Worker Survey
57.203_Healthcare Personnel Safety Reporting Plan Modified 5400 900 0 Form CDC 57.203 Healthcare Personnel Safety Monthly Reporting Plan
57.204_Healthcare Worker Demographic Data Modified 120000 40000 0 Form CDC 57.204 Healthcare Worker Demographic Data
57.205_Exposure to Blood and Body Fluids Modified 30000 30000 0 Form CDC 57.205 Exposure to Blood/Body Fluids
57.206_Healthcare Worker Post-Exposure Prophylaxis Modified 6000 1500 0 Form CDC 57.206 Healthcare Worker Prophylaxis/Treatment
57.207_Follow-up Laboratory Testing Modified 60000 15000 0 Form CDC 57.207 Follow-up Laboratory Testing
57.208_Healthcare Worker Vaccination History Modified 180000 30000 0 Form CDC 57.208 Healthcare Worker Vaccination History
57.209_Healthcare Worker Influenza Vaccination Modified 300000 50000 0 Form CDC Form 57.209 Healthcare Worker Influenza Vaccination
57.210_Healthcare Worker Influenza Antiviral Medication Administration Modified 30000 5000 0 Form CDC 57.210 Healthcare Worker Prophylaxis/Treatment
57.211_Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Modified 600 100 0 Form CDC 57.211 Pre-season Survey on Influenza Vaccination Programs for Healthcare Personnel
57.212_Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel Modified 600 100 0 Form CDC 57.212 Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel
57.213_Healthcare Personnel Influenza Vaccination Monthly Summary New 36000 72000 0 Form CDC 57.213 Healthcare Personnel Influenza Vaccination Monthly Summary
57.300_Hemovigilance Module Annual Survey Modified 500 1000 0 Form CDC 57.300 Hemovigilance Module Annual Facility Survey
57.301_Hemovigilance Module Monthly Reporting Plan Modified 6000 200 0 Form CDC 57.301 Hemovigilance Module Monthly Reporting Plan
57.302_Hemovigilance Module Blood Product Incident Reporting - Summary Data Modified 6000 12000 0 Form CDC 57.302 Hemovigilance Module Monthly Incident Summary
57.303_Hemovigilance Module Monthly Reporting Denominators Modified 6000 3000 0 Form CDC 57.303 hemovigilance Module Monthly Reporting Denominators
57.304_Hemovigilance Adverse Reaction Modified 60000 10000 0 Form CDC 57.304 Hemovigilance Module Adverse Reaction
57.305_Hemovigilance Module Adverse Reaction Modified 36000 6000 0 Form CDC 57.305 Hemovigilance Module Incident
Agreement to Participate and Consent Removed 0 0 0 Form 57.75T Agreement to Participate and Consent
List of Blood Isolates Removed 0 0 0 Form 57.75CC List of Blood Isolates
Manual Categorization of Positive Blood Cultures Removed 0 0 0 Form 57.75DD Manual Categorization of Positive Cultures
Total burden requested under this ICR: 8809350 3914125 162000  
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