Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
57.100 NHSN Registration Form Modified 2000 167 6307 Form 57.100
57.101 Facility Contact Information Modified 2000 333 12613 Form 57.101
57.103 Patient Safety Component - Annual Hospital Survey Modified 6000 3000 113520 Form 57.103
57.105 Group Contact Information Modified 6000 500 18920 Form 57.105
57.106 Patient Safety Monthly Reporting Plan Modified 72000 42000 1589280 Form 57.106
57.108 Primary Bloodstream Infection (BSI) Modified 216000 115200 4359168 Form 57.108
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram) Modified 432000 208800 7900992 Form 57.111
57.112 Ventilator-Associated Event (VAE) Modified 864000 316800 11987712 Form 57.112
57.114 Urinary Tract Infection (UTI) Modified 162000 78300 2962872 Form 57.114
57.116 Denominators for Neonatal Intensive Care Unit (NICU) Modified 54000 162000 5099760 Form 57.116
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC) Modified 54000 270000 8449600 Form 57.117
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA) Modified 324000 1620000 50997600 Form 57.118
57.120 Surgical Site Infection (SSI) Modified 216000 104400 3950496 Form 57.120
57.121 Denominators for Procedure Modified 3240000 270000 8499600 Form 57.121
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables Modified 72000 6000 107400 Form 57.123
57.124 Antimicrobial Use and Resistence (AUR) - Pharmacy Data Modified 72000 6000 84600 Form and Instruction 57.124
57.125 Central Line Insertion Practices Adherence Monitoring Form Modified 100000 8333 315333 Form 57.125
57.126 MDRO or CDI Infection Event Modified 432000 208800 7900992 Form 57.126
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring Modified 144000 28800 1089792 Form 57.127
57.128 Laboratory Identified or CDI MDRO Event Modified 1440000 360000 13622400 Form 57.128
57.130 Vaccination Monthly Monitoring Form - Summary Method Modified 500 7000 264880 Form 57.130
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method Modified 500 1000 37840 Form 57.131
57.133 Patient Vaccination Modified 25000 4167 157667 Form 57.133
57.137 Long Term care Facility Component--Annual Facility Survey Modified 250 188 7095 Form 57.137
57.138 Laboratory-Identified MDRO or CDI Event for LTCF Modified 2000 500 18920 Form 57.138
57.139 MDRO and CDI Monthly Monitoring for LTCF Modified 3000 250 9460 Form 57.139
57.140 Urinary Tract Infection (UTI) for LTCF Modified 2250 1013 38313 Form 57.140
57.141 Monthly Reporting Plan for LTCF Modified 3000 250 9460 Form 57.141
57.142 Denominators for LTCF Locations Modified 3000 9000 340560 Form 57.142
57.143 Prevention Process Measures Monthly Monitoring for LTCF Modified 3000 250 9460 Form 57.143
57.150 Patient Safety Component -- Annual Facility Survey for LTAC Modified 400 200 7568 Form 57.150
57.151 Patient Safety Component -- Annual Facility Survey for IRF Modified 1000 417 15767 Form 57.151
57.200 Healthcare Personnel Safety Component Facility Survey Modified 50 400 15940 Form 57.200
57.203 Healthcare Personnel Safety Reporting Plan Modified 450 75 2989 Form 57.203
57.204 Healthcare Worker Demographic Data Modified 10000 3333 132833 Form 57.204
57.205 Exposure to Blood and Body Fluids Modified 2500 2500 99625 Form 57.205
57.206 Healthcare Worker Prophylaxis/Treatment Modified 1500 375 14944 Form 57.206
57.207 Follow-up Laboratory Testing Modified 2500 625 11188 Form 57.207
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza Modified 2500 417 16604 Form 57.210
57.300 Hemovigilance Module Annual Facility Survey Modified 500 1000 33140 Form 57.300
57.301 Hemovigilance Module Monthly Reporting Plan Modified 6000 100 3314 Form 57.301
57.302 Hemovigilance Module Monthly Incident Summary Removed 0 0 0 Other-WORD
57.303 Hemovigilance Module Monthly Reporting Denominators Modified 6000 6000 198840 Form 57.303
57.304 Hemovigilance Module Adverse Reaction Modified 24000 6000 198840 Form 57.304
57.305 Hemovigilance Incident Modified 6000 1000 33140 Form 57.305
57.400 Outpatient Procedure - Annual Facility Survey New 5000 417 13117 Form 57.400
57.401 Outpatient Procedure - Monthly Reporting Plan New 60000 15000 472200 Form 57.401
57.402 Outpatient Procedure - Event New 125000 83333 2623333 Form 57.402
57.403 Outpatient Procedure - Monthly Denominators and Summary New 60000 40000 1259200 Form 57.403
57.500 Outpatient Dialysis Center Practices Survey Modified 6000 10500 340560 Form 57.500
57.501 Dialysis Monthly Reporting Plan New 72000 6000 188880 Form 57.501
57.502 Dialysis Event Modified 360000 78000 2455440 Form 57.502
57.503 Denominators for Outpatient Dialysis Modified 72000 7200 226656 Form 57.503
57.504 Prevention Process Measures Monthly Monitoring for Dialysis New 7200 3600 113328 Form 57.504
57.505 Dialysis Patient Influenza Vaccination New 18750 3125 98375 Form 57.505
57.506 Dialysis Patient Influenza Vaccination Denominator New 1250 208 6558 Form 57.506
57.600 State Health Department Validation Record New 7600 1900 59622 Form 57.600
Total burden requested under this ICR: 8810700 4104776 138604613  
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