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
57.101_Facility Contact Information Modified 6000 1000 0 Form CDC 57.101
57.103_Patient Safety Component Annual Facility Survey Modified 6000 4000 0 Form CDC 57.103
57.104_Patient Safety Component-- Outpatient Dialysis Center Practice Survey Modified 5500 5500 0 Form CDC 57.104
57.105_Group Contact Information Modified 6000 500 0 Form CDC 57.105
57.106_ Patient Safety Monthly Reporting Plan Modified 54000 31500 162000 Form CDC 57.106
57.108_Primary Bloodstream Infection (BSI) Modified 216000 115200 0 Form CDC 57.108
57.109_Dialysis Event Modified 37500 9375 0 Form CDC 57.109
57.111_Pneumonia (PNEU) Modified 432000 230400 0 Form CDC 57.111
57.114_Urinary Tract Infection (UTI) Modified 162000 86400 0 Form CDC 57.114
57.116_Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 216000 0 Form CDC 57.116
57.117_Denominators for Specialty Care Area (SCA) Modified 54000 270000 0 Form CDC 57.117
57.118_Denominators for Intensive Care Unit (ICU) Other Locations (not NICU or SCA) Modified 108000 540000 0 Form CDC 57.118
57.119_Denominators for Outpatient Dialysis Modified 6000 500 0 Form CDC 57.119
57.120_Surgical Site Infection (SSI) Modified 162000 86400 0 Form CDC 57.120
57.121_Denominators for Procedure Modified 3240000 540000 0 Form CDC 57.121
57.123_Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data Modified 72000 6000 0 Form CDC 57.123
57.124_Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 72000 6000 0 Form CDC 57.124
57.125_Central Line Insertion Practices Adherence Monitoring Form Modified 600000 50000 0 Form CDC 57.125
57.126_MDRO or CDI Infection Event Modified 432000 230400 0 Form CDC 57.126
57.127_Multi-drug Resistant Organism (MDRO) Prevention Process and Outcome Measures Monthly Monitoring Form Modified 144000 24000 0 Form CDC 57.127
57.128_Laboratory Identified MDRO Event Modified 1440000 600000 0 Form CDC 57.128
57.130_Vaccination Monthly Monitoring Form - Summary Method Modified 30000 420000 0 Form CDC 57.130
57.131_High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B Modified 10000 20000 0 Form CDC 57.131
57.133_Patient Vaccination Modified 500000 83333 0 Form CDC 57.133
57.137_Patient Safety Component --Annual Facility Survey for LTCF New 250 104 0 Form CDC 57.137
57.138 Laboratory-identified MDRO or CDI Event for LTCF New 2000 1000 0 Form 57.138
57.139_MDRO or CDI Prevention Process Measures Monthly Monitoring for LTCF New 750 88 0 Form CDC 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Modified 2250 1125 0 Form CDC 57.140
57.200_Healthcare Personnel Safety Component Facility Survey Modified 6000 48000 0 Form CDC 57.200
57.202_Healthcare Worker Survey Modified 60000 10000 0 Form CDC 57.202
57.203_Healthcare Personnel Safety Reporting Plan Modified 5400 900 0 Form CDC 57.203
57.204_Healthcare Worker Demographic Data Modified 120000 40000 0 Form CDC 57.204
57.205_Exposure to Blood and Body Fluids Modified 30000 30000 0 Form CDC 57.205
57.206_Healthcare Worker Post-Exposure Prophylaxis Modified 6000 1500 0 Form CDC 57.206
57.207_Follow-up Laboratory Testing Modified 60000 15000 0 Form CDC 57.207
57.208_Healthcare Worker Vaccination History Modified 180000 30000 0 Form CDC 57.208
57.209_Healthcare Worker Influenza Vaccination Modified 300000 50000 0 Form CDC Form 57.209
57.210_Healthcare Worker Influenza Antiviral Medication Administration Modified 30000 5000 0 Form CDC 57.210
57.211_Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Modified 600 100 0 Form CDC 57.211
57.212_Post-Season Survey on Influenza Vaccination Programs for Healthcare Personnel Modified 600 100 0 Form CDC 57.212
57.213_Healthcare Personnel Influenza Vaccination Monthly Summary New 36000 72000 0 Form CDC 57.213
57.300_Hemovigilance Module Annual Survey Modified 500 1000 0 Form CDC 57.300
57.301_Hemovigilance Module Monthly Reporting Plan Modified 6000 200 0 Form CDC 57.301
57.302_Hemovigilance Module Blood Product Incident Reporting - Summary Data Modified 6000 12000 0 Form CDC 57.302
57.303_Hemovigilance Module Monthly Reporting Denominators Modified 6000 3000 0 Form CDC 57.303
57.304_Hemovigilance Adverse Reaction Modified 60000 10000 0 Form CDC 57.304
57.305_Hemovigilance Module Adverse Reaction Modified 36000 6000 0 Form CDC 57.305
Agreement to Participate and Consent Removed 0 0 0 Form 57.75T
List of Blood Isolates Removed 0 0 0 Form 57.75CC
Manual Categorization of Positive Blood Cultures Removed 0 0 0 Form 57.75DD
Total burden requested under this ICR: 8809350 3914125 162000  
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