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Agenda
Reg Review
ICR
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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