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 57.100 NHSN Registration Form
57.101 Facility Contact Information Modified 6000 1000 0 Form 57.101 Facility Contact Information
57.103 Patient Safety Component Annual Facility Survey Modified 6000 4000 0 Form 57.103 Patient Safety Component -- Annual Facility Survey
57.104 Patient Safety Component --Outpatient Dialysis Center Practices Survey Modified 5500 5500 0 Form 57.104 Patient Safety Component--Outpatient Dialysis Center Practices Survey
57.105 Group Contact Information Modified 6000 500 0 Form 57.105 Group Contact Information
57.106 Patient Safety Monthly Reporting Plan Modified 54000 31500 162000 Form 57.106 Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI) Modified 216000 115200 0 Form 57.108 primary Bloodstream Infection (BSI)
57.109 Dialysis Event Modified 37500 9375 0 Form 57.109 Dialysis Event
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 432000 230400 0 Form 57.111 Pneumonia (PNEU)
57.114 Urinary Tract Infection (UTI) Modified 162000 86400 0 Form 57.114 Urinary Tract Infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 216000 0 Form 57.116 Denominators for Neonatal Intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA) Modified 54000 270000 0 Form 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 57.118 Denominator for Intensive Care Unit (ICU)/Other locations (not NICU or SCA)
57.119 Denominators for Outpatient Dialysis Modified 6000 500 0 Form 57.119 Denominators or Outpatient Dialysis
57.120 Surgical Site Infection (SSI) Modified 162000 86400 0 Form 57.120 Surgical Site Infection (SSI)
57.121 Denominators for Procedure Modified 3240000 540000 0 Form 57.121 Denominator for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Laboratory Data Modified 72000 6000 0 Form 57.123 Antimicrobial Use and Resistance (AUR)-Microbiology Data Electronic Upload Specification Tables
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 72000 6000 0 Form 57.124 Antimicrobial Use and Resistance (AUR)-Pharmacy Data Electronic Upload Specificaton Tables
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 600000 50000 0 Form 57.125 Central Line Insertion Practices (CLIP) Adherence Monitoring
57.126 MDRO Infection Event Modified 432000 230400 0 Form 57.126 MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 144000 24000 0 Form 57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
57.128 Laboratory Identified MDRO Event Modified 1440000 600000 0 Form 57.128 Laboratory-identified MDRO or CDI Event
57.130 High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method A Modified 30000 420000 0 Form 57.130 Vaccinatin Monthly Monitoring Form -Summary Method
57.131 High Risk Inpatient Influenza Vaccination Monthly Monitoring Form - Method B Modified 10000 20000 0 Form 57.131 Vaccination Monthkly Monitoring Form-Patient-Level Method
57.133 Patient Vaccination Modified 500000 83333 0 Form 57.133 Patient Vaccination
57.137 Patient Safety Component--Annual Facility Survey for LTCF New 250 104 0 Form 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 Laboratory-Identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF New 750 88 0 Form 57.139 MDRO and CDI Prevention Process Measures Monthly Monitoring for LTCF
57.140 High Risk Inpatient Influenza Vaccination Denominator Data Form - Method B Modified 2250 1125 0 Form 57.140 Urinary Tract Infection (UTI) for LTCF
57.200 Healthcare Personnel Safety Component Facility Survey Modified 6000 48000 0 Form 57.200 Healthcare Personnel Safety Component Annual Facility Survey
57.202 Healthcare Worker Survey Modified 60000 10000 0 Form 57.202 HealthCare Worker Survey
57.203 Healthcare Personnel Safety Reporting Plan Modified 5400 900 0 Form 57.203 Healthcare Personnel Safety Reporting Plan
57.204 Healthcare Worker Demographic Data Modified 120000 40000 0 Form 57.204 Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids Modified 30000 30000 0 Form 57.205 Exposure to Blood/Body Fluids
57.206 Healthcare Worker Post-Exposure Prophylaxis Modified 6000 1500 0 Form 57.206 Healthcare Worker Prophylaxis/Treatment
57.207 Laboratory Testing Modified 60000 15000 0 Form 57.207 Follow-up Laboratory Testing
57.208 Healthcare Worker Vaccination History Modified 180000 30000 0 Form 57.208 Healthcare Worker Vaccination History
57.209 Healthcare Worker Influenza Vaccination Modified 300000 50000 0 Form 57.209 Healthcare Worker Influenza Vaccinatuion
57.210 Healthcare Worker Influenza Antiviral Medication Administration Modified 30000 5000 0 Form 57.210 Healthcare Worker Prophylaxis/Treatment Influenza
57.211 Preseason Survey on Influenza Vaccination Program for Healthcare Personnel Modified 600 100 0 Form 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 57.212 Post-season Survey on Influenza Vaccination Programs for Health Personnel
57.213 Healthcare Personnel Influenza Vaccination Monthly Summary New 36000 72000 0 Form 57.213 Healthcare Personnel Influenza Vaccination Monthly Summary
57.300 Hemovigilance Module Annual Survey Modified 500 1000 0 Form 57.300 Hemovigilance Module Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan Modified 6000 200 0 Form 57.301 Hemovigilance Module Monthly Reporting Plan
57.302 Hemovigilance Module Blood Product Incident Reporting - Summary Data Modified 6000 12000 0 Form 57.302 Hemovigilance Module Monthly Incident Summary
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 3000 0 Form 57.303 Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Adverse Reaction Modified 60000 10000 0 Form 57.304 Hemovigilance Adverse Reaction
57.305 Hemovigilance Incident Modified 36000 6000 0 Form 57.305 Hemovigilance 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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