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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
2000
167
6307
Form
CDC 57.100
NHSN Registration Form
57.101 Facility Contact Information
Modified
2000
333
12613
Form
CDC 57.101
Facility Contact Information
57.103 Patient Safety Component - Annual Hospital Survey
Modified
6000
5000
113520
Form
CDC 57.103
Patient Safety Component--Annual Hospital Survey
57.105 Group Contact Information
Modified
1000
83
3153
Form
CDC 57.105
Group Contact Information
57.106 Patient Safety Monthly Reporting Plan
Modified
72000
18000
1589280
Form and Instruction
CDC 57.106
Patient Safety Monthly Reporting Plan
57.108 Primary Bloodstream Infection (BSI)
Modified
264000
132000
5327872
Form
CDC 57.108
Primary Bloodstreat Infection (BSI)
57.111 Pneumonia (includes Any Patient Pneumonia flow Diagram and Infant and Children Pneumonia Flow Diagram)
Modified
432000
216000
7900992
Form
CDC 57.111
Pneumonia (PNEU)
57.112 Ventilator-Associated Event (VAE)
Modified
864000
360000
11987712
Form
CDC 57.112
Ventilator-Associated Event (VAE)
57.114 Urinary Tract Infection (UTI)
Modified
240000
120000
4389440
Form
CDC 57.114
Urinary Tract Infection (UTI)
57.116 Denominators for Neonatal Intensive Care Unit (NICU)
Modified
54000
162000
5099760
Form
CDC 57.116
Denominators for Neonatal intensive Care Unit (NICU)
57.117 Denominators for Specialty Care Area (SCA)/Onocology (ONC)
Modified
54000
270000
8449600
Form
CDC 57.117
Denominators for Specialty Care Area (SCA) Oncology (ONC)
57.118 Denominators for Intensive Care Unit (ICU) Other Locations (Not NICU or SCA)
Modified
324000
1620000
50997600
Form
CDC 57.118
Denominators for Intensive Care Unit (ICU)/Other Locations (not NICU or SCA)
57.120 Surgical Site Infection (SSI)
Modified
216000
126000
3950496
Form
CDC 57.120
Surgical Site Infection (SSI)
57.121 Denominators for Procedure
Modified
3240000
270000
8499600
Form
CDC 57.121
Denominator for Procedure
57.123 Antimicrobial Use and Resistance (AUR) - Microbiology Data Upload Tables
Modified
72000
6000
107400
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
84600
Form and Instruction
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
100000
8333
315333
Form
CDC 57.125
Central Line Insertion Practices Adherence Monitoring
57.126 MDRO or CDI Infection Event
Modified
432000
216000
7900992
Form
CDC 57.126
MDRO or CDI Infection Event
57.127 MDRO and CDI Prevention Process and Outcome Measures Monthly Monitoring
Modified
144000
36000
1089792
Form
CDC 57.127
MDRO and CDI Prevention Process and Outcome Measures Monthly Reporting
57.128 Laboratory Identified or CDI MDRO Event
Modified
1440000
360000
13622400
Form
CDC 57.128
Laboratory-identified MDRO or CDI Event
57.130 Vaccination Monthly Monitoring Form - Summary Method
Removed
0
0
0
Form
57.130
Vaccination Monthly Monitoring - Summary Method
57.131 Vaccination Monthly Monitoring Form - Patient-Level Method
Removed
0
0
0
Form
57.131
Vaccination Monthly Monitoring - Patient level
57.133 Patient Vaccination
Removed
0
0
0
Form
57.133
Patient Vaccination
57.137 Long Term care Facility Component--Annual Facility Survey
Modified
250
250
7095
Form
CDC 57.137
Long Term Care Facility Component---Annual Facility Survey
57.138 Laboratory-Identified MDRO or CDI Event for LTCF
Modified
2000
500
18920
Form
CDC 57.138
Laboratory-identified MDRO or CDI Event for LTCF
57.139 MDRO and CDI Monthly Monitoring for LTCF
Modified
3000
250
9460
Form
CDC 57.139
MDRO and CDI Monthly Monitoring for LTCF
57.140 Urinary Tract Infection (UTI) for LTCF
Modified
2250
1125
38313
Form
CDC 57.140
Urinary Tract Infection (UTI) for LTCF
57.141 Monthly Reporting Plan for LTCF
Modified
3000
250
9460
Form
CDC 57.141
Monthly Reporting Plan for LTCF
57.142 Denominators for LTCF Locations
Modified
3000
9750
340560
Form
CDC 57.142
Denominators for LTCF
57.143 Prevention Process Measures Monthly Monitoring for LTCF
Modified
3000
250
9460
Form
CDC 57.143
Prevention Process Measures Monthly Monitoring
57.150 Patient Safety Component -- Annual Facility Survey for LTAC
Modified
400
333
7568
Form
CDC 57.150
Patient Safety Component---Annual Facility Survey for LTAC
57.151 Patient Safety Component -- Annual Facility Survey for IRF
Modified
1000
833
15767
Form
CDC 57.151
Patient Safety Component---Annual Facility Survey for IRF
57.200 Healthcare Personnel Safety Component Facility Survey
Modified
50
400
15940
Form
CDC 57.200
Healthcare Personnel Safety - Annual Facility Survey
57.203 Healthcare Personnel Safety Reporting Plan
Modified
11000
917
73064
Form
CDC 57.203
Healthcare Personnel Safety Monthly Reporting Plan
57.204 Healthcare Worker Demographic Data
Modified
10000
3333
132833
Form
CDC 57.204
Healthcare Worker Demographic Data
57.205 Exposure to Blood and Body Fluids
Modified
2500
2500
99625
Form
CDC 57.205
Exposure to Blood/Body Fluids
57.206 Healthcare Worker Prophylaxis/Treatment
Modified
1500
375
14944
Form
CDC 57.206
Healthcare Worker Prophylaxis/Treatment
57.207 Follow-up Laboratory Testing
Modified
2500
625
11188
Form
CDC 57.207
Follow-up Laboratory Testing
57.210 Healthcare Worker Prophylaxis/Treatment - Influenza
Modified
2500
417
16604
Form
CDC 57.210
HCW Prophylaxis/Treatment-Influenza
57.300 Hemovigilance Module Annual Facility Survey
Modified
500
1000
33140
Form
CDC 57.300
Hemovigilance Module Annual Survey
57.301 Hemovigilance Module Monthly Reporting Plan
Modified
6000
100
3314
Form
CDC 57.301
Hemovigilance Module Monthly Reporting Plan
57.303 Hemovigilance Module Monthly Reporting Denominators
Modified
6000
6000
198840
Form
CDC 57.303
Hemovigilance Module Monthly Reporting Denominators
57.304 Hemovigilance Module Adverse Reaction
Modified
24000
6000
198840
Form
CDC 57.304
Hemovigilance Adverse Reaction
57.305 Hemovigilance Incident
Modified
5000
833
27617
Form
CDC 57.305
Hemovigilance Module Monthly Reporting Denominators
57.400 Outpatient Procedure - Annual Facility Survey
Modified
5000
417
13117
Form
CDC 57.400
Outpatient Procedure---Annual Facility Survey
57.401 Outpatient Procedure - Monthly Reporting Plan
Modified
60000
15000
472200
Form
CDC 57.401
Outpatient Procedure Component Monthly Reporting Plan
57.402 Outpatient Procedure - Event
Modified
125000
83333
2623333
Form
CDC 57.402
Outpatient Procedure - Event
57.403 Outpatient Procedure - Monthly Denominators and Summary
Modified
60000
40000
1259200
Form
CDC 57.403
Outpatient Procedure - Monthly Denominators and Summary
57.500 Outpatient Dialysis Center Practices Survey
Modified
6500
11375
368940
Form and Instruction
CDC 57.500
Outpatient Dialysis Center Practices Survey
57.501 Dialysis Monthly Reporting Plan
Modified
78000
6500
204620
Form
CDC 57.501
NHSN Registration Form
57.502 Dialysis Event
Modified
390000
130000
2660060
Form
CDC 57.502
Dialysis Event
57.503 Denominators for Outpatient Dialysis
Modified
78000
7800
245544
Form and Instruction
CDC 57.503
Denominators for Dialysis Event Surveillance (Census Form)
57.504 Prevention Process Measures Monthly Monitoring for Dialysis
Modified
18000
9000
283320
Form
CDC 57-504
Prevention Process Measures Monthly Monitoring for Dialysis
57.505 Dialysis Patient Influenza Vaccination
Modified
24375
4063
127888
Form
CDC 57.505
Dialysis Patient Influenza Vaccination
57.506 Dialysis Patient Influenza Vaccination Denominator
Modified
1625
271
8525
Form
CDC 57.506
Dialysis Patient Influenza Vaccination Denominator
57.600 State Health Department Validation Record
Modified
7600
1900
59622
Form
CDC 57.600
State Health Department Validation Record
CDC 57.154 Antimicrobial Use & Resistance Component - Monthly Reporting Plan
New
1200
100
0
Form
CDC 57.154
Antimicrobial Use and Resistance Monthly Reporting Plan
Total burden requested under this ICR:
8975750
4277716
141057383
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